Provider Demographics
NPI:1154866598
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 1:1177 SILAS DEANE HWY
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4348
Mailing Address - Country:US
Mailing Address - Phone:860-249-1535
Mailing Address - Fax:
Practice Address - Street 1:1177 SILAS DEANE HWY
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4348
Practice Address - Country:US
Practice Address - Phone:860-249-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional