Provider Demographics
NPI:1528663903
Name:SHANNON, TARA ROSE
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:ROSE
Last Name:SHANNON
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 1:7704 ROMAINE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6228
Mailing Address - Country:US
Mailing Address - Phone:845-367-1034
Mailing Address - Fax:
Practice Address - Street 1:1545 SAWTELLE BLVD STE 31
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3272
Practice Address - Country:US
Practice Address - Phone:949-474-1493
Practice Address - Fax:949-726-8324
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty