Provider Demographics
NPI:1033447057
Name:GRAVIER, SHANNON NOEL (MFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NOEL
Last Name:GRAVIER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N DUTTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4687
Mailing Address - Country:US
Mailing Address - Phone:707-548-9220
Mailing Address - Fax:415-456-4822
Practice Address - Street 1:1360 N DUTTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4687
Practice Address - Country:US
Practice Address - Phone:707-548-9220
Practice Address - Fax:415-456-4822
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51188106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist