Provider Demographics
NPI:1326633207
Name:SHANNON, PATRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
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:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-0801
Mailing Address - Country:US
Mailing Address - Phone:208-651-1226
Mailing Address - Fax:
Practice Address - Street 1:3700 S RUSSELL ST STE B110
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8574
Practice Address - Country:US
Practice Address - Phone:406-763-6611
Practice Address - Fax:406-721-5072
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-483411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical