Provider Demographics
NPI:1891937306
Name:REILLY, SHANNON DENISE (CAS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DENISE
Last Name:REILLY
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-0586
Mailing Address - Country:US
Mailing Address - Phone:530-644-3758
Mailing Address - Fax:530-644-3782
Practice Address - Street 1:5494 PONY EXPRESS TRAIL
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726
Practice Address - Country:US
Practice Address - Phone:530-644-3758
Practice Address - Fax:530-644-3782
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility