Healthcare Provider Details

I. General information

NPI: 1558809608
Provider Name (Legal Business Name): SHELLYATTA JOHNSON BEARD LCSW 99953
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 UNION AVE
SAN JOSE CA
95124-5156
US

IV. Provider business mailing address

7910 S PINEWOOD DR
PINE BLUFF AR
71603-8963
US

V. Phone/Fax

Practice location:
  • Phone: 800-913-2615
  • Fax:
Mailing address:
  • Phone: 530-921-7648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10511-C
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: