Provider Demographics
NPI:1396253803
Name:SHADDOCK, DAVID R (MFT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:SHADDOCK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 ASHBY AVENUE,
Mailing Address - Street 2:# 105
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705
Mailing Address - Country:US
Mailing Address - Phone:510-836-1692
Mailing Address - Fax:
Practice Address - Street 1:3030 ASHBY AVENUE,
Practice Address - Street 2:# 105
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:510-836-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20360106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist