Provider Demographics
NPI:1467814798
Name:MILLARD, SHAYNE
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:MILLARD
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 1:180 SIERRA COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5768
Mailing Address - Country:US
Mailing Address - Phone:530-271-1140
Mailing Address - Fax:530-271-7036
Practice Address - Street 1:180 SIERRA COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5768
Practice Address - Country:US
Practice Address - Phone:530-271-1140
Practice Address - Fax:530-271-7036
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1234920716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)