Provider Demographics
NPI:1164553194
Name:SHANNON, JANIS A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANIS
Middle Name:A
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 SE FEDERAL HWY
Mailing Address - Street 2:#103
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4531
Mailing Address - Country:US
Mailing Address - Phone:772-882-8836
Mailing Address - Fax:
Practice Address - Street 1:2440 SE FEDERAL HWY
Practice Address - Street 2:#103
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4531
Practice Address - Country:US
Practice Address - Phone:772-882-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074605-11041C0700X
FLSW00841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ02HZOtherBCBS PROVIDER NUMBER