Provider Demographics
NPI:1962996678
Name:LITTLE, SHANNON (MA, APCC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LITTLE
Suffix:
Gender:F
Credentials:MA, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1220
Practice Address - Country:US
Practice Address - Phone:619-272-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health