Provider Demographics
NPI:1225844103
Name:DEMCHAK, SHANNON KATHLENN
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLENN
Last Name:DEMCHAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10549 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3513
Mailing Address - Country:US
Mailing Address - Phone:310-560-3853
Mailing Address - Fax:
Practice Address - Street 1:10549 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3513
Practice Address - Country:US
Practice Address - Phone:310-560-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT148955106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist