Provider Demographics
NPI:1750891321
Name:SHREVE, STEPHANIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:SHREVE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95415-0338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13500 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95415-9133
Practice Address - Country:US
Practice Address - Phone:707-895-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29428103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical