Provider Demographics
NPI:1568550077
Name:JOHNSON, SHANNON MOORE (LISAC, BA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MOORE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LISAC, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12033 AGENCY RD STE 730
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-7718
Mailing Address - Country:US
Mailing Address - Phone:928-669-3256
Mailing Address - Fax:928-669-3252
Practice Address - Street 1:12033 AGENCY RD STE 730
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3256
Practice Address - Fax:928-669-3252
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LISAC0725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ893885OtherAHCCCS