Provider Demographics
NPI:1184794448
Name:BREWER, SHANNON TAYLOR (MA, LPA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:BREWER
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 JOE V. KNOX AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9203
Mailing Address - Country:US
Mailing Address - Phone:704-663-6666
Mailing Address - Fax:704-663-5343
Practice Address - Street 1:132 JOE V. KNOX AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9203
Practice Address - Country:US
Practice Address - Phone:704-663-6666
Practice Address - Fax:704-663-5343
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2100103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2100OtherLPC LICENSE