Healthcare Provider Details

I. General information

NPI: 1265393094
Provider Name (Legal Business Name): SHANNON MICHAL LANCE ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7057 GASKIN PL
RIVERSIDE CA
92506-5615
US

IV. Provider business mailing address

7057 GASKIN PL
RIVERSIDE CA
92506-5615
US

V. Phone/Fax

Practice location:
  • Phone: 951-776-8869
  • Fax:
Mailing address:
  • Phone: 951-776-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW131737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: