Healthcare Provider Details

I. General information

NPI: 1043803232
Provider Name (Legal Business Name): SHANTELL HARRIS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1568 MCLEOD PL
POMONA CA
91768-1348
US

IV. Provider business mailing address

712 W MAXZIM AVE
FULLERTON CA
92832-3149
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-7543
  • Fax:
Mailing address:
  • Phone: 714-718-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: