Provider Demographics
NPI:1407866148
Name:ROMINE, SHANNON MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ROMINE
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 1:8920 SOUTHPOINTE DR
Mailing Address - Street 2:SUITE E-2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7509
Mailing Address - Country:US
Mailing Address - Phone:317-882-0427
Mailing Address - Fax:317-882-0851
Practice Address - Street 1:8920 SOUTHPOINTE DR
Practice Address - Street 2:SUITE E-2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7509
Practice Address - Country:US
Practice Address - Phone:317-882-0427
Practice Address - Fax:317-882-0851
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005117A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11590155OtherCAQH