Provider Demographics
NPI:1396861969
Name:LEGERE, SHANNON RYAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RYAN
Last Name:LEGERE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 GAVIOTA AVE UNIT 19
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:562-437-5072
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221031041C0700X
CANA171M00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner