Provider Demographics
NPI:1205301157
Name:SMITH, SHANNON (CCAPP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCAPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 E FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4206
Mailing Address - Country:US
Mailing Address - Phone:714-953-9373
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4206
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1328911118101YA0400X
CACCAPP101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1328911118Medicaid
CAR1328911118Medicaid