Provider Demographics
NPI:1942376736
Name:SHANNON, ALICE E (MFT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:E
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2780
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-2780
Mailing Address - Country:US
Mailing Address - Phone:707-839-0444
Mailing Address - Fax:707-839-1640
Practice Address - Street 1:607 F ST
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6325
Practice Address - Country:US
Practice Address - Phone:707-839-0444
Practice Address - Fax:707-839-1640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28722106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist