Provider Demographics
NPI:1518307164
Name:HUDDLESTON, SHANNON MARIKO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIKO
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIKO
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2325 CLEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-7063
Mailing Address - Country:US
Mailing Address - Phone:510-629-6300
Mailing Address - Fax:510-865-1930
Practice Address - Street 1:2325 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-7063
Practice Address - Country:US
Practice Address - Phone:510-629-6300
Practice Address - Fax:510-865-1930
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29981103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid