Healthcare Provider Details

I. General information

NPI: 1225118144
Provider Name (Legal Business Name): CYNTHIA JANE SHIPMAN I PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 LAKE PARK WAY 114
LA MESA CA
91942-1664
US

IV. Provider business mailing address

5575 LAKE PARK WAY 114
LA MESA CA
91942-1664
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-1155
  • Fax: 619-463-8986
Mailing address:
  • Phone: 619-463-1155
  • Fax: 619-463-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY5863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: