Provider Demographics
NPI:1316087307
Name:SAMPLES, SHANNON L (TBS COORDINATOR)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:TBS COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8357 SADDLE RD
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-7847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9860 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:UPPER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95485-9265
Practice Address - Country:US
Practice Address - Phone:707-275-8166
Practice Address - Fax:707-275-8168
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor