Provider Demographics
NPI:1801349972
Name:SHANKS, KRISTY (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:SHANKS
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 1:2828 COLLEGE AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2138
Mailing Address - Country:US
Mailing Address - Phone:608-214-0657
Mailing Address - Fax:
Practice Address - Street 1:5297 COLLEGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1797
Practice Address - Country:US
Practice Address - Phone:510-788-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA84091101YM0800X, 104100000X
CA103353104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health