Provider Demographics
NPI:1669784617
Name:TANNER, SHONDELL RAMONA (MS)
Entity type:Individual
Prefix:MS
First Name:SHONDELL
Middle Name:RAMONA
Last Name:TANNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-526-1476
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142319101YP2500X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional