Provider Demographics
NPI:1154799773
Name:MARTIN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTIN
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 1:310 HARRIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3249
Mailing Address - Country:US
Mailing Address - Phone:916-649-6793
Mailing Address - Fax:916-928-7411
Practice Address - Street 1:310 HARRIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838
Practice Address - Country:US
Practice Address - Phone:916-649-6793
Practice Address - Fax:916-929-7411
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R1194201315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA150914000060OtherWELLSPACE HEALTH