Provider Demographics
NPI:1770048472
Name:THOMPSON, SHANTORIA SHANAE
Entity type:Individual
Prefix:
First Name:SHANTORIA
Middle Name:SHANAE
Last Name:THOMPSON
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 1:1023 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-2913
Mailing Address - Country:US
Mailing Address - Phone:510-880-9910
Mailing Address - Fax:
Practice Address - Street 1:1999 HARRISON ST STE 1800
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-4700
Practice Address - Country:US
Practice Address - Phone:916-720-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician