Provider Demographics
NPI:1194230094
Name:COMERY, SHANNON LATRAE SR
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LATRAE
Last Name:COMERY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-4309
Mailing Address - Country:US
Mailing Address - Phone:225-264-6670
Mailing Address - Fax:
Practice Address - Street 1:206 CLINIC DR
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346
Practice Address - Country:US
Practice Address - Phone:225-264-6670
Practice Address - Fax:225-264-6671
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health