Provider Demographics
NPI:1790917987
Name:SHANNON, KAIYA (LCSW)
Entity Type:Individual
Prefix:
First Name:KAIYA
Middle Name:
Last Name:SHANNON
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6050
Mailing Address - Fax:239-343-6051
Practice Address - Street 1:15901 BASS RD STE 108
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3838
Practice Address - Country:US
Practice Address - Phone:239-343-6050
Practice Address - Fax:239-343-6051
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 95201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical