Provider Demographics
NPI:1568892016
Name:KOSTUCK, SHANNON (MSW, LCSW-A)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:KOSTUCK
Suffix:
Gender:F
Credentials:MSW, LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 PETERS CREEK PKWY
Mailing Address - Street 2:SUITE 20-22
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3726
Mailing Address - Country:US
Mailing Address - Phone:336-761-5300
Mailing Address - Fax:336-761-5319
Practice Address - Street 1:2101 PETERS CREEK PKWY
Practice Address - Street 2:SUITE 20-22
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-3726
Practice Address - Country:US
Practice Address - Phone:336-761-5300
Practice Address - Fax:336-761-5319
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0079071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical