Provider Demographics
NPI:1932673829
Name:FRALEY, SHANNEN LEIGH (MFT)
Entity Type:Individual
Prefix:
First Name:SHANNEN
Middle Name:LEIGH
Last Name:FRALEY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9483 PAJARO LN
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-9104
Mailing Address - Country:US
Mailing Address - Phone:707-953-4110
Mailing Address - Fax:
Practice Address - Street 1:509 7TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5265
Practice Address - Country:US
Practice Address - Phone:707-568-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT47636106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist