Provider Demographics
NPI:1093015257
Name:ROBERSON, SHANNON (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROBERSON
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 1:225 S MAIN ST
Mailing Address - Street 2:STE. 103
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2866
Mailing Address - Country:US
Mailing Address - Phone:636-294-0015
Mailing Address - Fax:
Practice Address - Street 1:225 S MAIN ST
Practice Address - Street 2:STE. 103
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2866
Practice Address - Country:US
Practice Address - Phone:636-294-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010012405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional