Provider Demographics
NPI:1164300588
Name:DELGADO-PRUSMACK, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:DELGADO-PRUSMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 E EL CAMINO REAL APT 69
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2826
Mailing Address - Country:US
Mailing Address - Phone:650-209-0273
Mailing Address - Fax:
Practice Address - Street 1:2660 SOLACE PL STE B
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4337
Practice Address - Country:US
Practice Address - Phone:650-564-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79471225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist