Provider Demographics
NPI:1083409379
Name:HIRASE, SHANNON LYNNE
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LYNNE
Last Name:HIRASE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNNE
Other - Last Name:RANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 N THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9086
Mailing Address - Country:US
Mailing Address - Phone:805-474-3300
Mailing Address - Fax:
Practice Address - Street 1:525 N THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9086
Practice Address - Country:US
Practice Address - Phone:805-474-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool