Provider Demographics
NPI:1164767778
Name:CHURCH, SHANNON ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ANN
Last Name:CHURCH
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 1:11150 HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4110
Mailing Address - Country:US
Mailing Address - Phone:228-867-5202
Mailing Address - Fax:228-867-5007
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:STE 410
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-867-5202
Practice Address - Fax:228-867-5007
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC25621041C0700X
LA29991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical