Healthcare Provider Details

I. General information

NPI: 1992967996
Provider Name (Legal Business Name): SHANNON DUBACH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 BANCROFT WAY STE 307
BERKELEY CA
94704-1406
US

IV. Provider business mailing address

2041 BANCROFT WAY STE 307
BERKELEY CA
94704-1406
US

V. Phone/Fax

Practice location:
  • Phone: 510-686-3773
  • Fax: 510-649-1133
Mailing address:
  • Phone: 510-686-3773
  • Fax: 510-649-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY24793
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY24793
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: