Active NPI
Carolyn B. Shadduck, PH.D., PSY.D.
- Clinical Psychologist
- Santa Monica, CA
National Provider Identifier
1891710125
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY4871
- Practice address
- 636 26TH St
Santa Monica, CA 90402-3148 - Phone
- (310) 395-0436
- Fax
- (310) 395-1887
- NPI assigned
- Jul 13, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY4871 | CA | Primary |
Addresses
Primary practice location
636 26TH St
Santa Monica, CA 90402-3148
Mailing address
636 26TH St
Santa Monica, CA 90402-3148
Phone (310) 395-0436
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| PSY4871 | Other | CA | LICENSE AS A PSYCHOLOGIST |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
- Opted out of Medicare
- Yes, effective Jul 1, 2015 through Jul 1, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY4871 | CA | MD | Clinical Psychologist |
| 4871 | CA | MD | Speech-Language Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152748800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1891710125",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "636 26TH ST",
"city": "SANTA MONICA",
"state": "CA",
"postal_code": "904023148",
"telephone_number": "310-395-0436",
"fax_number": "310-395-1887"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "636 26TH ST",
"city": "SANTA MONICA",
"state": "CA",
"postal_code": "904023148",
"telephone_number": "310-395-0436",
"fax_number": "310-395-1887"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHADDUCK",
"first_name": "CAROLYN",
"middle_name": "B.",
"name_prefix": "Dr.",
"credential": "PH.D., PSY.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-07-13",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY4871",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE AS A PSYCHOLOGIST",
"identifier": "PSY4871",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Santa Monica, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.