Provider Demographics
NPI:1346670064
Name:GRESHAM, SHANNON STEWART (MS, LAC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:STEWART
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 RINGGOLD AVE
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019-9078
Mailing Address - Country:US
Mailing Address - Phone:318-932-4029
Mailing Address - Fax:318-932-5914
Practice Address - Street 1:1313 RINGGOLD AVE
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9078
Practice Address - Country:US
Practice Address - Phone:318-932-4029
Practice Address - Fax:318-932-5914
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC #1408101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)