Healthcare Provider Details

I. General information

NPI: 1871912949
Provider Name (Legal Business Name): VINCENT SHANKS PSYM, PSYD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44415 KINGSTON DR
TEMECULA CA
92592-5621
US

IV. Provider business mailing address

44415 KINGSTON DR
TEMECULA CA
92592-5621
US

V. Phone/Fax

Practice location:
  • Phone: 951-265-0809
  • Fax: 951-302-2038
Mailing address:
  • Phone: 951-265-0809
  • Fax: 951-302-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: