Provider Demographics
NPI:1144989815
Name:MYRICK, SHELBY (CADC I)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:MYRICK
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 RANCHO WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-4558
Mailing Address - Country:US
Mailing Address - Phone:707-974-7061
Mailing Address - Fax:
Practice Address - Street 1:825 RANCHO WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-4558
Practice Address - Country:US
Practice Address - Phone:707-974-7061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI28691219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)