Provider Demographics
NPI:1083806095
Name:SMITH, SHANNON (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1129 TROTWOOD AVE STE 24
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3046
Practice Address - Country:US
Practice Address - Phone:931-334-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529273Medicaid