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General NPI Number Information
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NPI Number | 1679443287
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Entity Type | Individual
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Provider Name | THADDEUS PETER SHAFER
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Gender | Male
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Dates
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Enumeration Date | 11/08/2025
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Last Update Date | 11/08/2025
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Provider Practice Location Address
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Address Line | 2400 MISSION ST # 208
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City | SAN MARINO
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State | CA
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Zip | 91108-1632
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Country | US
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Telephone | 626-765-1753
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2032
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City | TOLUCA LAKE
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State | CA
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Zip | 91610-0032
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Country | US
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Telephone | 323-413-7812
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 155389
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License Number State | CA
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