Provider Demographics
NPI:1396368817
Name:CANNON, SHANNON MARIE (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 SUMMERS ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-3131
Mailing Address - Country:US
Mailing Address - Phone:318-465-7794
Mailing Address - Fax:
Practice Address - Street 1:1543 SUMMERS ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-3131
Practice Address - Country:US
Practice Address - Phone:318-465-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16132104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker