Provider Demographics
NPI:1568626729
Name:WATSON, SHANELLE
Entity type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:WATSON
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 1:16425 HARBOR BLVD APT 247
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-8311
Mailing Address - Country:US
Mailing Address - Phone:310-783-4677
Mailing Address - Fax:
Practice Address - Street 1:16425 HARBOR BLVD
Practice Address - Street 2:APT 247
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-8311
Practice Address - Country:US
Practice Address - Phone:310-783-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health