Provider Demographics
NPI:1265842801
Name:SHANNON, PAULA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAULA
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 1:1007 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1317
Mailing Address - Country:US
Mailing Address - Phone:309-582-3789
Mailing Address - Fax:309-582-3735
Practice Address - Street 1:1007 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1317
Practice Address - Country:US
Practice Address - Phone:309-582-3789
Practice Address - Fax:309-582-3735
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490161721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical