Provider Demographics
NPI:1316266281
Name:BADER, SHANNON MARIE (PHD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 9TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6435
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-7552
Practice Address - Fax:909-425-6407
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22905103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical