Healthcare Provider Details

I. General information

NPI: 1376876375
Provider Name (Legal Business Name): SHELLY ZAVALA MFT, PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST SUITE 204
NEWPORT BEACH CA
92660-2840
US

IV. Provider business mailing address

1151 DOVE STREET SUITE 204
NEWPORT BEACH CA
92660
US

V. Phone/Fax

Practice location:
  • Phone: 949-752-7955
  • Fax: 949-752-7955
Mailing address:
  • Phone: 949-752-7955
  • Fax: 949-752-7955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT39381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: