Provider Demographics
NPI:1558846709
Name:SHADD, MARCEL JAMES (COUNSELOR 1)
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:JAMES
Last Name:SHADD
Suffix:
Gender:M
Credentials:COUNSELOR 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SAN PABLO AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4281
Mailing Address - Country:US
Mailing Address - Phone:916-572-7641
Mailing Address - Fax:
Practice Address - Street 1:6400 TUPELO DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1741
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15808101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)