=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356396998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY LYNN SHANNON PSYD LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 02/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41865 BOARDWALK STE 217
-----------------------------------------------------
City | PALM DESERT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92211-9033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-488-5054
-----------------------------------------------------
Fax | 760-488-5059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 39
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-0039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-488-5054
-----------------------------------------------------
Fax | 760-488-5059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC7912
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------