Provider Demographics
NPI:1639311293
Name:DICKSON, SHANNON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:DICKSON
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 1:2716 X ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2725
Mailing Address - Country:US
Mailing Address - Phone:916-455-5506
Mailing Address - Fax:
Practice Address - Street 1:2716 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2725
Practice Address - Country:US
Practice Address - Phone:916-455-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-29
Last Update Date:2009-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X, 103TC2200X
CAPSY17692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent