Provider Demographics
NPI:1730641408
Name:PROPHET, SHEA
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:PROPHET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 PACIFIC AVE APT H
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2338
Mailing Address - Country:US
Mailing Address - Phone:915-549-2339
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3410
Practice Address - Country:US
Practice Address - Phone:194-813-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist