Provider Demographics
NPI:1992967996
Name:DUBACH, SHANNON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:DUBACH
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 1:2041 BANCROFT WAY STE 307
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1406
Mailing Address - Country:US
Mailing Address - Phone:510-686-3773
Mailing Address - Fax:510-649-1133
Practice Address - Street 1:2041 BANCROFT WAY STE 307
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1406
Practice Address - Country:US
Practice Address - Phone:510-686-3773
Practice Address - Fax:510-649-1133
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24793103TA0700X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent