Provider Demographics
NPI:1073703179
Name:BODE, SHANNON ERIKA MARIE (BA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ERIKA MARIE
Last Name:BODE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 8TH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2500
Mailing Address - Country:US
Mailing Address - Phone:510-693-8240
Mailing Address - Fax:
Practice Address - Street 1:4175 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-5774
Practice Address - Country:US
Practice Address - Phone:510-262-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT77737106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist