Healthcare Provider Details

I. General information

NPI: 1356902597
Provider Name (Legal Business Name): SHANNON KILGORE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 N GLASSELL ST
ORANGE CA
92867-6748
US

IV. Provider business mailing address

594 N GLASSELL ST
ORANGE CA
92867-6748
US

V. Phone/Fax

Practice location:
  • Phone: 657-859-1861
  • Fax:
Mailing address:
  • Phone: 657-859-1861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number109195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: