Healthcare Provider Details

I. General information

NPI: 1316441132
Provider Name (Legal Business Name): MRS. SHANNON HEYWARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1196 THIRD AVE
CHULA VISTA CA
91911-3131
US

IV. Provider business mailing address

1196 THIRD AVE
CHULA VISTA CA
91911-3131
US

V. Phone/Fax

Practice location:
  • Phone: 619-427-4661
  • Fax:
Mailing address:
  • Phone: 619-427-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114553
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: