Provider Demographics
NPI:1457020901
Name:PHILLIPS, SHAWNA (SAC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4619
Mailing Address - Country:US
Mailing Address - Phone:209-527-9797
Mailing Address - Fax:209-527-9825
Practice Address - Street 1:823 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4619
Practice Address - Country:US
Practice Address - Phone:209-527-9797
Practice Address - Fax:209-527-9825
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)