Provider Demographics
NPI:1669872578
Name:PRINCE, SHADARIA RENE (LCSW)
Entity type:Individual
Prefix:
First Name:SHADARIA
Middle Name:RENE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4183 W WELDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6893
Mailing Address - Country:US
Mailing Address - Phone:310-654-9835
Mailing Address - Fax:
Practice Address - Street 1:2600 VENTURA ST STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-3041
Practice Address - Country:US
Practice Address - Phone:310-654-9835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW675431041C0700X
CALCSW948001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health