Provider Demographics
NPI:1730386442
Name:RUCKER, SHANNON SHERNEICE (MFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHERNEICE
Last Name:RUCKER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 BROADWAY STREET
Mailing Address - Street 2:SUITE #3
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5670
Mailing Address - Country:US
Mailing Address - Phone:510-725-7450
Mailing Address - Fax:510-923-9006
Practice Address - Street 1:4000 BROADWAY
Practice Address - Street 2:SUITE #3
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5670
Practice Address - Country:US
Practice Address - Phone:510-725-7450
Practice Address - Fax:510-923-9006
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43728106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist