Provider Demographics
NPI:1639592843
Name:DEITCH, SHANNON L (LPC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:DEITCH
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 1:3913 SPRING CIRCLE DR E
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-9385
Mailing Address - Country:US
Mailing Address - Phone:281-788-6807
Mailing Address - Fax:
Practice Address - Street 1:105 N GORDON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-2718
Practice Address - Country:US
Practice Address - Phone:281-585-0000
Practice Address - Fax:281-585-0080
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66956101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional