Provider Demographics
NPI:1417288101
Name:SHANNON, AMANDA (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:506 GROVER ST STE 112
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1960
Mailing Address - Country:US
Mailing Address - Phone:360-383-8682
Mailing Address - Fax:360-255-0439
Practice Address - Street 1:506 GROVER ST STE 112
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264
Practice Address - Country:US
Practice Address - Phone:360-383-8682
Practice Address - Fax:360-255-0439
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG 60146874101YM0800X
101YM0800X
CA61542101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007301Medicaid