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General NPI Number Information
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NPI Number | 1699055673
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Entity Type | Individual
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Provider Name | SHANNON G. CONVERSE
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Gender | Female
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Dates
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Enumeration Date | 08/23/2011
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Last Update Date | 08/23/2011
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Provider Practice Location Address
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Address Line | 610 14TH ST
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City | MODESTO
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State | CA
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Zip | 95354-2505
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Country | US
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Telephone | 209-524-4858
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Fax |
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Provider Business Mailing Address
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Address Line | 4208 FARA BIUNDO DR
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City | MODESTO
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State | CA
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Zip | 95355-9794
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Country | US
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Telephone | 209-526-5019
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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 |
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License Number State |
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