Provider Demographics
NPI:1649829474
Name:CARROLL, SHAYNA ALYSE
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:ALYSE
Last Name:CARROLL
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 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:213-381-3626
Mailing Address - Fax:213-380-8923
Practice Address - Street 1:11643 GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1050
Practice Address - Country:US
Practice Address - Phone:818-897-2609
Practice Address - Fax:818-890-7159
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA115324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator