Healthcare Provider Details

I. General information

NPI: 1285269761
Provider Name (Legal Business Name): SHAWN DEFFENBAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 BAIRD AVE
RESEDA CA
91335-4150
US

IV. Provider business mailing address

2722 MAGNOLIA ST
CAMARILLO CA
93012-8032
US

V. Phone/Fax

Practice location:
  • Phone: 818-342-5897
  • Fax:
Mailing address:
  • Phone: 805-336-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1322800918
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: