Provider Demographics
NPI:1174027957
Name:WALDRUP, SHANNON (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALDRUP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S WHITE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-4732
Mailing Address - Country:US
Mailing Address - Phone:423-746-0163
Mailing Address - Fax:
Practice Address - Street 1:404 S WHITE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4732
Practice Address - Country:US
Practice Address - Phone:423-746-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker