Provider Demographics
NPI:1902165343
Name:APODACA, SHANNON P
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:P
Last Name:APODACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:P
Other - Last Name:FUKUSHIMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3123 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7595
Mailing Address - Country:US
Mailing Address - Phone:510-461-5512
Mailing Address - Fax:
Practice Address - Street 1:1020 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-4521
Practice Address - Country:US
Practice Address - Phone:209-695-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)