Healthcare Provider Details

I. General information

NPI: 1548669500
Provider Name (Legal Business Name): SHANNON BRECKENRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON TURNER

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TULLY RD # STUA-2
MODESTO CA
95350-2946
US

IV. Provider business mailing address

972 OAK GROVE RD
MODESTO CA
95351
US

V. Phone/Fax

Practice location:
  • Phone: 209-622-1420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number68828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: