Provider Demographics
NPI:1538675574
Name:MITCHELL, SHANNON EILEEN (LICSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:EILEEN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:EILEEN
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:2016 E 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6474
Mailing Address - Country:US
Mailing Address - Phone:509-863-6822
Mailing Address - Fax:509-228-3116
Practice Address - Street 1:2814 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2528
Practice Address - Country:US
Practice Address - Phone:509-863-6822
Practice Address - Fax:509-228-3116
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW601604401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2114136Medicaid