Healthcare Provider Details

I. General information

NPI: 1932613585
Provider Name (Legal Business Name): SHAWONIA MONIQUE WYSINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 GOUGH ST
SAN FRANCISCO CA
94102-5903
US

IV. Provider business mailing address

101 GOUGH ST
SAN FRANCISCO CA
94102-5903
US

V. Phone/Fax

Practice location:
  • Phone: 415-553-4490
  • Fax:
Mailing address:
  • Phone: 415-553-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10711-R
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: