Provider Demographics
NPI:1588845531
Name:THREADGILL, SHANNON (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THREADGILL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:SZKOTNICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7110 W JULIE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5830
Mailing Address - Country:US
Mailing Address - Phone:602-703-3557
Mailing Address - Fax:
Practice Address - Street 1:18205 N 51ST AVE BLDG B
Practice Address - Street 2:SUITE 115
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1490
Practice Address - Country:US
Practice Address - Phone:602-703-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ116881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical