Provider Demographics
NPI:1902791056
Name:SIBLEY, SHANNON VERMICE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:VERMICE
Last Name:SIBLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W ROSECRANS AVE APT 89
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-2433
Mailing Address - Country:US
Mailing Address - Phone:323-568-9444
Mailing Address - Fax:
Practice Address - Street 1:8616 LA TIJERA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3944
Practice Address - Country:US
Practice Address - Phone:310-337-7827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7JPB447106S00000X, 103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst