Provider Demographics
NPI:1174248934
Name:SPICER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SPICER
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 1:4250 FOWLER LN STE 204
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9782
Mailing Address - Country:US
Mailing Address - Phone:916-221-8721
Mailing Address - Fax:
Practice Address - Street 1:4250 FOWLER LN STE 204
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9782
Practice Address - Country:US
Practice Address - Phone:530-295-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA171M00000X
CA145762106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator