Provider Demographics
NPI:1275007601
Name:BATES, SHANNON M (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BATES
Suffix:
Gender:F
Credentials:MSW, LCSW
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 750
Mailing Address - Street 2:
Mailing Address - City:HOOPA
Mailing Address - State:CA
Mailing Address - Zip Code:95546-0750
Mailing Address - Country:US
Mailing Address - Phone:541-261-9511
Mailing Address - Fax:
Practice Address - Street 1:38883 CA-299
Practice Address - Street 2:
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573
Practice Address - Country:US
Practice Address - Phone:530-629-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW70857101Y00000X
CA936491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor