Provider Demographics
NPI:1407109408
Name:KROENKE, SHANNON MARIE (MSW, LCSW, MT-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:KROENKE
Suffix:
Gender:F
Credentials:MSW, LCSW, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E 8TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3294
Mailing Address - Country:US
Mailing Address - Phone:360-524-2126
Mailing Address - Fax:360-953-8533
Practice Address - Street 1:101 E 8TH ST STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3294
Practice Address - Country:US
Practice Address - Phone:360-524-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW608872541041C0700X, 171000000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171000000XOther Service ProvidersMilitary Health Care Provider