Provider Demographics
NPI:1992725451
Name:MONG, SHANNON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:MONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BON AIR RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1702
Mailing Address - Country:US
Mailing Address - Phone:415-499-3240
Mailing Address - Fax:415-499-6033
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-499-3240
Practice Address - Fax:415-499-6033
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20722OtherPSYCHOLOGIST LICENSE