Provider Demographics
NPI:1215534359
Name:BREITENSTEIN, SHANNON CHRISTINE (LMHC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:CHRISTINE
Last Name:BREITENSTEIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2432
Mailing Address - Country:US
Mailing Address - Phone:319-361-4248
Mailing Address - Fax:
Practice Address - Street 1:3920 GLASS RD NE APT B
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2508
Practice Address - Country:US
Practice Address - Phone:319-361-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health