Provider Demographics
NPI:1780749416
Name:SHANNON, KATHLEEN NOELLE (MA, MFC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:NOELLE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MA, MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7086
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-7086
Mailing Address - Country:US
Mailing Address - Phone:928-925-2467
Mailing Address - Fax:714-969-8808
Practice Address - Street 1:18811 HUNTINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648
Practice Address - Country:US
Practice Address - Phone:928-925-2467
Practice Address - Fax:714-969-8808
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZC.A.D.A.C. 1591101YA0400X
AZL.P.C. 2093101YM0800X
CA49712106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health