Provider Demographics
NPI:1639891823
Name:FENN, SHARLEEN M (SUDRC)
Entity Type:Individual
Prefix:
First Name:SHARLEEN
Middle Name:M
Last Name:FENN
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-1927
Mailing Address - Country:US
Mailing Address - Phone:510-825-7032
Mailing Address - Fax:
Practice Address - Street 1:5625 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1927
Practice Address - Country:US
Practice Address - Phone:510-825-7072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)