Provider Demographics
NPI:1306358387
Name:HAMILTON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 LANTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-3854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 LANTON RD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3854
Practice Address - Country:US
Practice Address - Phone:417-256-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022028935103TC1900X, 101YP2500X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician