Provider Demographics
NPI:1891075149
Name:FLYNN, SHANNON M (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 RAVINIA CT
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-9444
Mailing Address - Country:US
Mailing Address - Phone:815-585-1019
Mailing Address - Fax:
Practice Address - Street 1:1111 RAVINIA CT
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-9444
Practice Address - Country:US
Practice Address - Phone:815-585-1019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA279884101Y00000X
IL180012013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180012013OtherILLINOIS LCPC LICENSE NUMBER