Provider Demographics
NPI:1215222823
Name:WIGHT, SHANNON DANILE (CAS1)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DANILE
Last Name:WIGHT
Suffix:
Gender:F
Credentials:CAS1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0087
Mailing Address - Country:US
Mailing Address - Phone:209-381-6850
Mailing Address - Fax:209-385-3174
Practice Address - Street 1:301 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-381-6850
Practice Address - Fax:209-385-3174
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02-090691101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)