Provider Demographics
NPI:1760735237
Name:SMITH, SHANNON LAUREL (ASW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LAUREL
Last Name:SMITH
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 6TH AVE
Mailing Address - Street 2:APT 17
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1968
Mailing Address - Country:US
Mailing Address - Phone:510-479-2026
Mailing Address - Fax:
Practice Address - Street 1:39500 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2211
Practice Address - Country:US
Practice Address - Phone:510-226-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34627104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker