Provider Demographics
NPI:1134978752
Name:THORNBURG, SHANNON RACHEL
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RACHEL
Last Name:THORNBURG
Suffix:
Gender:F
Credentials:
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 1549
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-1549
Mailing Address - Country:US
Mailing Address - Phone:971-320-9082
Mailing Address - Fax:
Practice Address - Street 1:224 KAMEHAMEHA AVE # 201
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2860
Practice Address - Country:US
Practice Address - Phone:971-320-9082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health