Healthcare Provider Details

I. General information

NPI: 1124956495
Provider Name (Legal Business Name): NICOLE MARIE SHREVE SUDRC 1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3648 EL PORTAL DR
REDDING CA
96002-3133
US

IV. Provider business mailing address

22670 RIO ALTO DR
COTTONWOOD CA
96022-7932
US

V. Phone/Fax

Practice location:
  • Phone: 530-722-1114
  • Fax:
Mailing address:
  • Phone: 530-354-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: