Provider Demographics
NPI:1518356005
Name:PECKHAM, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PECKHAM
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 1:222 W MISSION AVE
Mailing Address - Street 2:#104
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2344
Mailing Address - Country:US
Mailing Address - Phone:509-668-8070
Mailing Address - Fax:
Practice Address - Street 1:222 W MISSION AVE
Practice Address - Street 2:#104
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2344
Practice Address - Country:US
Practice Address - Phone:509-668-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006173101YM0800X
WAFC00000162101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional