Provider Demographics
NPI:1487377784
Name:BLACK, SHANNON LEE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:BLACK
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 1:1000 WINDY PASS SPC 154
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-5476
Mailing Address - Country:US
Mailing Address - Phone:442-455-8822
Mailing Address - Fax:
Practice Address - Street 1:16248 VICTOR ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3934
Practice Address - Country:US
Practice Address - Phone:760-243-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3727585OtherSUBSTANCE USE DISORDER