Provider Demographics
NPI:1053812883
Name:SHEPHERD, RAEVAN MONICA (ASW)
Entity type:Individual
Prefix:
First Name:RAEVAN
Middle Name:MONICA
Last Name:SHEPHERD
Suffix:
Gender:
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 LAKESHORE BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6971
Mailing Address - Country:US
Mailing Address - Phone:707-295-2304
Mailing Address - Fax:707-998-0122
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8458
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1183331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)