Healthcare Provider Details

I. General information

NPI: 1003451907
Provider Name (Legal Business Name): RAYMOND SHELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 BRADSHAW RD STE 140
SACRAMENTO CA
95827-2697
US

IV. Provider business mailing address

18726 S WESTERN AVE STE 408
GARDENA CA
90248-3858
US

V. Phone/Fax

Practice location:
  • Phone: 916-245-4133
  • Fax: 855-568-2494
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-51325
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: