Provider Demographics
NPI:1679273445
Name:BUNDY, SHANE' S (ACSW)
Entity type:Individual
Prefix:MS
First Name:SHANE'
Middle Name:S
Last Name:BUNDY
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 SAWTELLE BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7013
Mailing Address - Country:US
Mailing Address - Phone:323-766-6989
Mailing Address - Fax:
Practice Address - Street 1:25345 WOODCREEK CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4445
Practice Address - Country:US
Practice Address - Phone:951-534-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA899111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical