Healthcare Provider Details

I. General information

NPI: 1588152417
Provider Name (Legal Business Name): SHADA MARIE PATTERSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23041 AVENIDA DE LA CARLOTA FL 4
LAGUNA HILLS CA
92653-1511
US

IV. Provider business mailing address

7725 GATEWAY UNIT 3235
IRVINE CA
92618-5844
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-6480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: