Provider Demographics
NPI:1528307717
Name:EWORONSKY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:EWORONSKY
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 1:44199 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3096
Mailing Address - Country:US
Mailing Address - Phone:760-770-2286
Mailing Address - Fax:760-770-2240
Practice Address - Street 1:44199 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3096
Practice Address - Country:US
Practice Address - Phone:760-770-2286
Practice Address - Fax:760-770-2240
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC26511214171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator