Provider Demographics
NPI:1639881253
Name:MOORE, SHANNON VICTORIA (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VICTORIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2015
Mailing Address - Country:US
Mailing Address - Phone:908-963-6776
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9494
Practice Address - Country:US
Practice Address - Phone:707-624-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical