Provider Demographics
NPI:1225320823
Name:SHANNON, ERIN (LCSW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:SHANNON
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 1:302 N EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5506
Mailing Address - Country:US
Mailing Address - Phone:708-941-8254
Mailing Address - Fax:
Practice Address - Street 1:302 N EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5506
Practice Address - Country:US
Practice Address - Phone:708-941-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-14
Last Update Date:2011-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0144871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical