Provider Demographics
NPI:1184917346
Name:BROWN, SHANNON LAVON (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LAVON
Last Name:BROWN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:
Practice Address - Street 1:1001 N 7TH AVE STE 135
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5790
Practice Address - Country:US
Practice Address - Phone:208-425-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-332261041C0700X
IDLSW 29478104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker