Healthcare Provider Details

I. General information

NPI: 1922502525
Provider Name (Legal Business Name): SHAWNA MCCANN CADC 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

2743 ORANGE ST
RIVERSIDE CA
92501-2538
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-0021
  • Fax:
Mailing address:
  • Phone: 951-781-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI10001217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: