Basic Information
| Provider Information | |||||||||
| NPI: | 1275007601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 750 | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955460750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412619511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 38883 CA-299 | ||||||||
| Address2: | |||||||||
| City: | WILLOW CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306293111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2019 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | ASW70857 | CA | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 93649 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.