Provider Demographics
NPI:1871240796
Name:PHILLIPS, SHANNA N (MA)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:N
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 HIDDEN CV
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1171
Mailing Address - Country:US
Mailing Address - Phone:540-519-2590
Mailing Address - Fax:
Practice Address - Street 1:1313 QUARRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-6002
Practice Address - Country:US
Practice Address - Phone:304-981-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool