Provider Demographics
NPI:1235207689
Name:ANKROM, SHIRLEY DAWN (MS, LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:DAWN
Last Name:ANKROM
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:DAWN
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC, NCC
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-0575
Mailing Address - Country:US
Mailing Address - Phone:417-839-1779
Mailing Address - Fax:888-839-9210
Practice Address - Street 1:1407 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2103
Practice Address - Country:US
Practice Address - Phone:417-839-1779
Practice Address - Fax:888-839-9210
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005003223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO49284OtherNBCC
MO2005003223OtherLICENSED PRACTICAL COUNSE
MOSDA3992127OtherCTS WITH DSS
MO497483404Medicaid