Provider Demographics
NPI:1538298658
Name:SHANNON, VIRGINIA (LCSW)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:SHANNON
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 1:152 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-2574
Mailing Address - Country:US
Mailing Address - Phone:321-632-5792
Mailing Address - Fax:321-632-5796
Practice Address - Street 1:220 CORAL SANDS DR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2720
Practice Address - Country:US
Practice Address - Phone:321-632-5792
Practice Address - Fax:321-632-5796
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 5110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7905ZMedicare ID - Type Unspecified