Healthcare Provider Details

I. General information

NPI: 1750646063
Provider Name (Legal Business Name): SHARI SAMUEL I DOCTORATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2908 ASHBROOK CT
MODESTO CA
95355-8623
US

IV. Provider business mailing address

2908 ASHBROOK CT
MODESTO CA
95355-8623
US

V. Phone/Fax

Practice location:
  • Phone: 916-890-6255
  • Fax:
Mailing address:
  • Phone: 916-890-6255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12500
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC5584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: