Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | R1375050120 | CA |
NPI | 1003433137 |
---|---|
Provider Name | Shawna Michaele Mongiovi |
First Address | Perris, CA 92570-2200 |
Second Address | Perris, CA 92570-2200 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2020 |
Last Update Date | 06/07/2020 |