Provider Demographics
NPI:1992180830
Name:CONWAY, SHEA (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:CONWAY
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2971 BRIDGEPORT SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:FIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95629-9609
Mailing Address - Country:US
Mailing Address - Phone:530-409-4308
Mailing Address - Fax:
Practice Address - Street 1:32 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-4231
Practice Address - Country:US
Practice Address - Phone:530-409-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF87094106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist