Provider Demographics
NPI:1487101606
Name:SHAFA, SHAHAM
Entity type:Individual
Prefix:
First Name:SHAHAM
Middle Name:
Last Name:SHAFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 W VENTURA ST
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1876
Mailing Address - Country:US
Mailing Address - Phone:805-524-8645
Mailing Address - Fax:
Practice Address - Street 1:125 W THOUSAND OAKS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4461
Practice Address - Country:US
Practice Address - Phone:805-777-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132355106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist