Healthcare Provider Details

I. General information

NPI: 1003086869
Provider Name (Legal Business Name): SHANNON COUSINS-KAMARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HOWE AVE
SACRAMENTO CA
95825-4731
US

IV. Provider business mailing address

149 CINEMA ST
SACRAMENTO CA
95823-7320
US

V. Phone/Fax

Practice location:
  • Phone: 916-993-4131
  • Fax:
Mailing address:
  • Phone: 916-991-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: