Healthcare Provider Details

I. General information

NPI: 1518271576
Provider Name (Legal Business Name): JOHANNA MARIE MCSHANE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 DEWING AVE STE E
LAFAYETTE CA
94549-4246
US

IV. Provider business mailing address

936 DEWING AVE STE E
LAFAYETTE CA
94549-4246
US

V. Phone/Fax

Practice location:
  • Phone: 925-283-9377
  • Fax: 925-934-5419
Mailing address:
  • Phone: 925-283-9377
  • Fax: 925-934-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY23662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: