Provider Demographics
NPI:1174038954
Name:JAMES, SHANNON MARIE (MSW, LCSW, SAC-IT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:JAMES
Suffix:
Gender:F
Credentials:MSW, LCSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3448
Mailing Address - Country:US
Mailing Address - Phone:414-336-8651
Mailing Address - Fax:
Practice Address - Street 1:9730 W BLUEMOUND RD STE 11
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4455
Practice Address - Country:US
Practice Address - Phone:414-336-0525
Practice Address - Fax:414-930-2986
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI91331041C0700X
WI130473-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10004541Medicaid