Healthcare Provider Details

I. General information

NPI: 1265145981
Provider Name (Legal Business Name): SHEENA BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13925 SAN PABLO AVE
RICHMOND CA
94806-3652
US

IV. Provider business mailing address

1646 S WRIGHT RD
SANTA ROSA CA
95407-7318
US

V. Phone/Fax

Practice location:
  • Phone: 510-525-6225
  • Fax:
Mailing address:
  • Phone: 707-856-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: