Provider Demographics
NPI:1669969416
Name:SHIRLEY, KAREN LEANNE (SUDCC11)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LEANNE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:SUDCC11
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SUNRISE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4106
Mailing Address - Country:US
Mailing Address - Phone:916-782-3737
Mailing Address - Fax:
Practice Address - Street 1:406 SUNRISE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4106
Practice Address - Country:US
Practice Address - Phone:916-782-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15383101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-1582683OtherALCOHOL AND DRUG TREATMENT