Basic Information
| Provider Information | |||||||||
| NPI: | 1952408601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETTENCOURT | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3331 POWER INN RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958263889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168753392 | ||||||||
| FaxNumber: | 9168759970 | ||||||||
| Practice Location | |||||||||
| Address1: | 3331 POWER INN RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958263889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168753392 | ||||||||
| FaxNumber: | 9168759970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC42581 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.