Provider Demographics
NPI:1619639762
Name:KOSSICK, SHANNON LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:KOSSICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 MOLLY DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-2643
Mailing Address - Country:US
Mailing Address - Phone:916-751-9899
Mailing Address - Fax:
Practice Address - Street 1:205 S PRATT AVE
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-4730
Practice Address - Country:US
Practice Address - Phone:775-882-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11331-C1041C0700X
NVIC-1733104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical