Provider Demographics
NPI:1124618442
Name:GRANIGAN-DEMUTH, SHANNON RAE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:GRANIGAN-DEMUTH
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 1:410 JONES ST STE C1
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5491
Mailing Address - Country:US
Mailing Address - Phone:707-463-0405
Mailing Address - Fax:707-313-4999
Practice Address - Street 1:410 JONES ST STE C1
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5491
Practice Address - Country:US
Practice Address - Phone:707-463-0405
Practice Address - Fax:707-313-4999
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA101YM0800X
CA143116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health