Provider Demographics
NPI:1306219456
Name:HAGAN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:4161 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3219
Mailing Address - Country:US
Mailing Address - Phone:415-967-0421
Mailing Address - Fax:
Practice Address - Street 1:2397 SHATTUCK AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1567
Practice Address - Country:US
Practice Address - Phone:415-967-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27814103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical