Provider Demographics
NPI:1417151648
Name:SHANNON, CHAQUITA SHANTA
Entity Type:Individual
Prefix:
First Name:CHAQUITA
Middle Name:SHANTA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 KINGS CROSS LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5179
Mailing Address - Country:US
Mailing Address - Phone:662-346-6570
Mailing Address - Fax:
Practice Address - Street 1:1689 NONCONNAH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2111
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2021-09-14
Deactivation Date:2021-08-20
Deactivation Code:
Reactivation Date:2021-09-09
Provider Licenses
StateLicense IDTaxonomies
TN7626104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7626OtherLICENSED MASTER SOCIAL WORKER