Healthcare Provider Details

I. General information

NPI: 1124618442
Provider Name (Legal Business Name): SHANNON RAE GRANIGAN-DEMUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 JONES ST STE C1
UKIAH CA
95482-5491
US

IV. Provider business mailing address

410 JONES ST STE C1
UKIAH CA
95482-5491
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-0405
  • Fax: 707-313-4999
Mailing address:
  • Phone: 707-463-0405
  • Fax: 707-313-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number143116
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: