Provider Demographics
NPI:1194851808
Name:PARK, SHANNON ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ELAINE
Last Name:PARK
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 1:145 S, HOLLY STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3101
Mailing Address - Country:US
Mailing Address - Phone:541-773-5664
Mailing Address - Fax:541-773-5667
Practice Address - Street 1:145 S, HOLLY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3101
Practice Address - Country:US
Practice Address - Phone:541-773-5664
Practice Address - Fax:541-773-5667
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL33391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL3339OtherLICENSE NUMBER