Provider Demographics
NPI:1760504096
Name:WEISE, SHANNON M (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:WEISE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:WEISE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:624 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW CUMBERLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17070
Mailing Address - Country:US
Mailing Address - Phone:717-461-7933
Mailing Address - Fax:717-474-3452
Practice Address - Street 1:2601 N FRONT ST STE 106
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1123
Practice Address - Country:US
Practice Address - Phone:717-461-7933
Practice Address - Fax:717-474-3452
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0160161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100775933Medicaid