Healthcare Provider Details

I. General information

NPI: 1033785563
Provider Name (Legal Business Name): SHAE THYSSE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9057 SOQUEL DRIVE BLDG C, SUITE A
APTOS CA
95003
US

IV. Provider business mailing address

380 ENCINAL ST STE 200
SANTA CRUZ CA
95060-2178
US

V. Phone/Fax

Practice location:
  • Phone: 831-662-1303
  • Fax:
Mailing address:
  • Phone: 831-469-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: