Healthcare Provider Details

I. General information

NPI: 1700354214
Provider Name (Legal Business Name): SHANNON ANTHONY PEREIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7460 MISSION VALLEY RD STE 200
SAN DIEGO CA
92108-4438
US

IV. Provider business mailing address

7090 MIRATECH DR
SAN DIEGO CA
92121-3109
US

V. Phone/Fax

Practice location:
  • Phone: 619-376-6653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: