Provider Demographics
NPI:1538120852
Name:SHANNON, TERESA Z (LMHC)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:Z
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:TERESA
Other - Middle Name:Z
Other - Last Name:ESTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:1332 DEERPATH RD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-5847
Mailing Address - Country:US
Mailing Address - Phone:850-573-7747
Mailing Address - Fax:
Practice Address - Street 1:1332 DEERPATH RD
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-5847
Practice Address - Country:US
Practice Address - Phone:850-573-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7036101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678049196Medicaid