Provider Demographics
NPI:1376957373
Name:KENNEY, SHANA GAVIGLIO
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:GAVIGLIO
Last Name:KENNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2211
Mailing Address - Country:US
Mailing Address - Phone:415-258-9572
Mailing Address - Fax:415-258-9572
Practice Address - Street 1:1665 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2211
Practice Address - Country:US
Practice Address - Phone:415-258-9572
Practice Address - Fax:415-258-9572
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health