Provider Demographics
NPI:1063824019
Name:IHORN, SHASTA MARIE (PHD)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:MARIE
Last Name:IHORN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 BROADWAY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1761 BROADWAY ST
Practice Address - Street 2:STE 100
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2226
Practice Address - Country:US
Practice Address - Phone:707-645-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist