Provider Demographics
NPI:1770053258
Name:SHUTKOVA, OKSANA A
Entity type:Individual
Prefix:
First Name:OKSANA
Middle Name:A
Last Name:SHUTKOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 EL CAMINO AVENUE
Mailing Address - Street 2:APPT #19
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821
Mailing Address - Country:US
Mailing Address - Phone:916-247-6942
Mailing Address - Fax:
Practice Address - Street 1:2823 EL CAMINO AVENUE
Practice Address - Street 2:APPT #19
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821
Practice Address - Country:US
Practice Address - Phone:916-247-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1116396351OtherKAISER