=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053812883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAEVAN MONICA SHEPHERD ASW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2018
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9055 HWY 53
-----------------------------------------------------
City | LOWER LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95422-8458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-994-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2681 LAKESHORE BLVD APT 7
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-6971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-295-2304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 118333
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------