=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265997936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANDA M ANGIOLI PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2019
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4640 CASS ST # 90422
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-274-0874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 90422
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92169-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PSY30699
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY30699
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------