Provider Demographics
NPI:1679994727
Name:SHOUSE, AMY (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHOUSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BAYO VISTA WAY APT 28
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1699
Mailing Address - Country:US
Mailing Address - Phone:415-635-9933
Mailing Address - Fax:
Practice Address - Street 1:712 D ST STE D
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3705
Practice Address - Country:US
Practice Address - Phone:415-635-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15707171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist