Healthcare Provider Details

I. General information

NPI: 1679288666
Provider Name (Legal Business Name): SHANNON LERACH, PH.D., INC., A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 N HIGHWAY 101 STE 16
SOLANA BEACH CA
92075-1167
US

IV. Provider business mailing address

243 N HIGHWAY 101 STE 16
SOLANA BEACH CA
92075-1167
US

V. Phone/Fax

Practice location:
  • Phone: 619-817-5320
  • Fax:
Mailing address:
  • Phone: 619-817-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANNON LERACH
Title or Position: OWNER
Credential: PH.D.
Phone: 619-817-5320