Healthcare Provider Details

I. General information

NPI: 1336421502
Provider Name (Legal Business Name): SHONDALE FIELDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 RIVER RD
SALINAS CA
93908-9601
US

IV. Provider business mailing address

1400 PARKMOOR AVE #115
SAN JOSE CA
95126-3797
US

V. Phone/Fax

Practice location:
  • Phone: 831-455-4767
  • Fax:
Mailing address:
  • Phone: 408-510-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF77661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: