Provider Demographics
NPI:1629256607
Name:GRETHEL, SHANNON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:GRETHEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:KFRC- NEUROPSYCHOLOGY DEPARTMENT
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:707-651-4547
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:KFRC- NEUROPSYCHOLOGY DEPARTMENT
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:832-370-7960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-01
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21763103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist