Lisa Staab Shadburn, PSY.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY17173 Issued in CA

Practice address

630 Mission St
Suite C2
South Pasadena, CA 91030-3058

Phone

(626) 403-3040

NPI assigned

Mar 17, 2007

Last updated

Mar 24, 2010By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174089600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1269388800000",
    "number": "1033233952",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1540 E COLORADO ST",
            "city": "GLENDALE",
            "state": "CA",
            "postal_code": "912051514",
            "telephone_number": "818-244-7257"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "630 MISSION ST",
            "address_2": "SUITE C2",
            "city": "SOUTH PASADENA",
            "state": "CA",
            "postal_code": "910303058",
            "telephone_number": "626-403-3040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "STAAB SHADBURN",
        "first_name": "LISA",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-03-17",
        "last_updated": "2010-03-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "CA",
            "license": "PSY17173",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY17173",
            "primary": true
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "",
            "desc": "Psychologist, Counseling",
            "state": "CA",
            "license": "PSY17173",
            "primary": false
        },
        {
            "code": "103TC2200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "CA",
            "license": "PSY17173",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in South Pasadena, CA
• Providers in South Pasadena, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.