Healthcare Provider Details

I. General information

NPI: 1386046688
Provider Name (Legal Business Name): SHANNON EDMISTON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 MILLER WAY
SACRAMENTO CA
95817-1332
US

IV. Provider business mailing address

4049 MILLER WAY
SACRAMENTO CA
95817-1332
US

V. Phone/Fax

Practice location:
  • Phone: 916-451-9312
  • Fax:
Mailing address:
  • Phone: 916-451-9312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1250850517
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: