Provider Demographics
NPI:1952671927
Name:PHILLIPS, SHANNON (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MATTINGLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:1115 MADISON ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:381 HOLDER LN SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-1946
Practice Address - Country:US
Practice Address - Phone:503-450-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4758101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional