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General NPI Number Information
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NPI Number | 1588465157
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Entity Type | Individual
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Provider Name | SHANE MICHAEL SHEPARD SUDRC
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Gender | Male
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Dates
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Enumeration Date | 03/20/2025
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 484 PLEASANT VALLEY ROAD #4
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City | DIAMOND SPRINGS
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State | CA
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Zip | 95619-9561
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Country | US
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Telephone | 530-344-7633
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Fax |
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Provider Business Mailing Address
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Address Line | 484 PLESANT VALLEY RD. #4
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City | DIAMOND SPRINGS
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State | CA
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Zip | 95619
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Country | US
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Telephone | 530-344-7633
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 20980
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License Number State | CA
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