Provider Demographics
NPI:1144803420
Name:MARTIN, SHANNON L (LPC LIC # 2018028478)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC LIC # 2018028478
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 HILL N DALE DR
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-5101
Mailing Address - Country:US
Mailing Address - Phone:417-501-9560
Mailing Address - Fax:
Practice Address - Street 1:1000 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2634
Practice Address - Country:US
Practice Address - Phone:573-774-5353
Practice Address - Fax:573-774-2907
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174662720Medicaid