Provider Demographics
NPI:1558619742
Name:TAYLOR, SHANNON LEA (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEA
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 WASHINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2842
Mailing Address - Country:US
Mailing Address - Phone:207-871-1211
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:40 MAIN ST BLDG 13
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-5178
Practice Address - Country:US
Practice Address - Phone:207-871-1200
Practice Address - Fax:207-871-1232
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC133631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical