Provider Demographics
NPI:1326735846
Name:CONNER, SHANNA LEIGH (MFT-A)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEIGH
Last Name:CONNER
Suffix:
Gender:F
Credentials:MFT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12122 WOOD GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-4530
Mailing Address - Country:US
Mailing Address - Phone:260-310-9804
Mailing Address - Fax:
Practice Address - Street 1:6331 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1547
Practice Address - Country:US
Practice Address - Phone:260-310-9804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000504A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist