Provider Demographics
NPI:1659052660
Name:SHANNON, HEATHER L (LMSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-5006
Mailing Address - Country:US
Mailing Address - Phone:714-625-5546
Mailing Address - Fax:
Practice Address - Street 1:213 N MAIN ST STE 1B
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2700
Practice Address - Country:US
Practice Address - Phone:208-683-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-392511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical