Healthcare Provider Details

I. General information

NPI: 1073233664
Provider Name (Legal Business Name): SHELLEY SHOWALTER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30495 CANWOOD ST STE 101
AGOURA HILLS CA
91301-4331
US

IV. Provider business mailing address

30495 CANWOOD ST STE 101
AGOURA HILLS CA
91301-4331
US

V. Phone/Fax

Practice location:
  • Phone: 818-707-7366
  • Fax:
Mailing address:
  • Phone: 818-707-7366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number19205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: