Provider Demographics
NPI:1174186274
Name:STAVINOHA, SHANNON L (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:STAVINOHA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 W HIGHWAY 290 P.O. BOX # 50225
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735
Mailing Address - Country:US
Mailing Address - Phone:903-914-0224
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD STE I7
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8659
Practice Address - Country:US
Practice Address - Phone:903-914-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38174103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling