Provider Demographics
NPI:1629707633
Name:UPDIKE, SHANNON (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:UPDIKE
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 1:1030 OLD BON AIR RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4835
Mailing Address - Country:US
Mailing Address - Phone:804-201-9006
Mailing Address - Fax:504-717-5121
Practice Address - Street 1:1030 OLD BON AIR RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4835
Practice Address - Country:US
Practice Address - Phone:804-201-9006
Practice Address - Fax:504-717-5121
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040074031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical