Healthcare Provider Details

I. General information

NPI: 1528307717
Provider Name (Legal Business Name): SHANNON EWORONSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44199 MONROE ST
INDIO CA
92201-3096
US

IV. Provider business mailing address

44199 MONROE ST
INDIO CA
92201-3096
US

V. Phone/Fax

Practice location:
  • Phone: 760-770-2286
  • Fax: 760-770-2240
Mailing address:
  • Phone: 760-770-2286
  • Fax: 760-770-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberC26511214
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC26511214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: