Provider Demographics
NPI:1396174512
Name:SQUILLANTE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SQUILLANTE
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 1:1187 E 3RD ST UNIT 308
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3582
Mailing Address - Country:US
Mailing Address - Phone:805-304-4190
Mailing Address - Fax:
Practice Address - Street 1:4025 W 226TH ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2340
Practice Address - Country:US
Practice Address - Phone:310-373-4556
Practice Address - Fax:310-375-1784
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98938106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist