Provider Demographics
NPI:1568949139
Name:PANKONIN, SHAWNA MICHELLE (LPC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MICHELLE
Last Name:PANKONIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12932 SARACENNIA RD
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-7708
Mailing Address - Country:US
Mailing Address - Phone:228-297-4420
Mailing Address - Fax:
Practice Address - Street 1:12932 SARACENNIA RD
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39562-7708
Practice Address - Country:US
Practice Address - Phone:228-297-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health