Provider Demographics
NPI:1811018427
Name:LICANO, SHANNON T
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:T
Last Name:LICANO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:T
Other - Last Name:LINLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:
Practice Address - Street 1:4449 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4520
Practice Address - Country:US
Practice Address - Phone:602-279-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
AZ104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist