Healthcare Provider Details

I. General information

NPI: 1861536831
Provider Name (Legal Business Name): SHANNON T JOHNSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

IV. Provider business mailing address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7679
  • Fax: 909-425-6635
Mailing address:
  • Phone: 909-425-7679
  • Fax: 909-425-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: