Provider Demographics
NPI:1003402694
Name:HUMPHRIES, SHANNON COLEMAN (ALC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:COLEMAN
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 GLYNWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5533
Mailing Address - Country:US
Mailing Address - Phone:334-358-2455
Mailing Address - Fax:
Practice Address - Street 1:1820 GLYNWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5533
Practice Address - Country:US
Practice Address - Phone:334-358-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2358A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional