Healthcare Provider Details

I. General information

NPI: 1265997936
Provider Name (Legal Business Name): SHANDA M ANGIOLI PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 CASS ST # 90422
SAN DIEGO CA
92109-2804
US

IV. Provider business mailing address

PO BOX 90422
SAN DIEGO CA
92169-2422
US

V. Phone/Fax

Practice location:
  • Phone: 858-274-0874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30699
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY30699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: