Provider Demographics
NPI:1588247407
Name:COMBS, SHANNON (RADT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:COMBS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 GREAT OAKS BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1314
Mailing Address - Country:US
Mailing Address - Phone:408-502-2037
Mailing Address - Fax:
Practice Address - Street 1:90 GREAT OAKS BLVD STE 108
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1314
Practice Address - Country:US
Practice Address - Phone:408-502-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1393140620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty