Provider Demographics
NPI:1063104255
Name:ROESLER, SHANELLE
Entity type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:ROESLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 REED AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5130
Mailing Address - Country:US
Mailing Address - Phone:925-337-2525
Mailing Address - Fax:
Practice Address - Street 1:10065 OLD GROVE RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1664
Practice Address - Country:US
Practice Address - Phone:858-547-9803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248744106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist