Provider Demographics
NPI:1922604966
Name:PERRY-SMITH, SHANNON (LCMHC, LCAS, NCC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PERRY-SMITH
Suffix:
Gender:F
Credentials:LCMHC, LCAS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 CAPITOL DR # 9-10
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-7398
Mailing Address - Country:US
Mailing Address - Phone:919-764-4601
Mailing Address - Fax:
Practice Address - Street 1:2555 CAPITOL DR STE 9
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-7398
Practice Address - Country:US
Practice Address - Phone:919-764-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25652101YA0400X
NCA15217101YM0800X
NC15217101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922604966Medicaid