Provider Demographics
NPI:1760799902
Name:VITRO, SHANNON MARIE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:VITRO
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 1:4010 FOOTHILLS BLVD STE 103
Mailing Address - Street 2:PMB 134
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7241
Mailing Address - Country:US
Mailing Address - Phone:916-251-9674
Mailing Address - Fax:
Practice Address - Street 1:5701 LONETREE BLVD
Practice Address - Street 2:SUITE 321
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3772
Practice Address - Country:US
Practice Address - Phone:916-251-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA748111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical