Provider Demographics
NPI:1922319938
Name:BURKE, SHANNON MARIE (LPCC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DINGO RD
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-5498
Mailing Address - Country:US
Mailing Address - Phone:505-220-6971
Mailing Address - Fax:505-832-4441
Practice Address - Street 1:1209 W US ROUTE 66 STE A
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-1039
Practice Address - Country:US
Practice Address - Phone:505-220-6971
Practice Address - Fax:505-832-4441
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0130231101YM0800X
NM0156191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841738820OtherBILLING NPI