Healthcare Provider Details

I. General information

NPI: 1114475282
Provider Name (Legal Business Name): SHANNON HARTMAN M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9003 RESEDA BLVD STE 103
NORTHRIDGE CA
91324-3939
US

IV. Provider business mailing address

9003 RESEDA BLVD STE 103
NORTHRIDGE CA
91324-3939
US

V. Phone/Fax

Practice location:
  • Phone: 818-465-9368
  • Fax: 818-921-4182
Mailing address:
  • Phone: 818-465-9368
  • Fax: 818-921-4182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: