Provider Demographics
NPI:1639684806
Name:ECHOLS, SHALINE
Entity Type:Individual
Prefix:
First Name:SHALINE
Middle Name:
Last Name:ECHOLS
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 1:93 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 SONOMA HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-4024
Practice Address - Country:US
Practice Address - Phone:707-526-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12008-ROtherAODS COUNSELOR
CA12961900OtherKAISER PERMANENTE