Provider Demographics
NPI:1861705188
Name:STOVALL, SHANNON ELYSE (LPC, PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELYSE
Last Name:STOVALL
Suffix:
Gender:F
Credentials:LPC, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39465 PASEO PADRE PKWY
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5350
Mailing Address - Country:US
Mailing Address - Phone:210-542-4616
Mailing Address - Fax:
Practice Address - Street 1:39465 PASEO PADRE PKWY
Practice Address - Street 2:SUITE 2100
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-5350
Practice Address - Country:US
Practice Address - Phone:510-745-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64885101YP2500X
CA26755103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling