Healthcare Provider Details

I. General information

NPI: 1689349847
Provider Name (Legal Business Name): SHAWN MARIA CARLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 HENDLEY ST
SANTA ROSA CA
95404-5025
US

IV. Provider business mailing address

450 STONY POINT RD APT 130
SANTA ROSA CA
95401-5987
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-0412
  • Fax:
Mailing address:
  • Phone: 707-393-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: