Provider Demographics
NPI:1689850083
Name:CROSS, SHANNON LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:CROSS
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 1:8520 SHRUB CT
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2961
Mailing Address - Country:US
Mailing Address - Phone:801-518-6379
Mailing Address - Fax:
Practice Address - Street 1:4105 TUDOR CENTRE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5902
Practice Address - Country:US
Practice Address - Phone:907-565-4000
Practice Address - Fax:907-565-4011
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT524665335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52466533501OtherSTATE LICENSE