Provider Demographics
NPI:1124355821
Name:PADILLA, SHANNON (LBSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3695 HOT SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9549
Mailing Address - Country:US
Mailing Address - Phone:505-454-2100
Mailing Address - Fax:505-454-2130
Practice Address - Street 1:700 FRIEDMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4231
Practice Address - Country:US
Practice Address - Phone:505-454-5100
Practice Address - Fax:505-454-0397
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-4069104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker