Provider Demographics
NPI:1093230823
Name:SHANAZ IKONNE, PLLC
Entity Type:Organization
Organization Name:SHANAZ IKONNE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANAZ
Authorized Official - Middle Name:SARA
Authorized Official - Last Name:IKONNE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:469-626-9085
Mailing Address - Street 1:7500 S IH 35 UNIT 523
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-6626
Mailing Address - Country:US
Mailing Address - Phone:469-626-9085
Mailing Address - Fax:
Practice Address - Street 1:1021 RANCH ROAD 620 S STE B
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5611
Practice Address - Country:US
Practice Address - Phone:469-626-9085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty