Provider Demographics
NPI:1861076283
Name:WARD, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:WARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:GARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5514
Mailing Address - Country:US
Mailing Address - Phone:619-977-3716
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5514
Practice Address - Country:US
Practice Address - Phone:619-977-3716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X, 171M00000X
CAASW101230101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator