Healthcare Provider Details

I. General information

NPI: 1255565867
Provider Name (Legal Business Name): SHANNON RYAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MIDDLE RINCON RD
SANTA ROSA CA
95409-3107
US

IV. Provider business mailing address

540 MIDDLE RINCON RD
SANTA ROSA CA
95409-3107
US

V. Phone/Fax

Practice location:
  • Phone: 707-909-0168
  • Fax:
Mailing address:
  • Phone: 707-909-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number44076
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number01154
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: