=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134933732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANIC LAURELL DAVIDSON ASW
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2025
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5445 LAUREL HILLS DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95841-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-710-5890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6061
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93703-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-759-1293
-----------------------------------------------------
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 | ASW128147
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------