Provider Demographics
NPI:1265238133
Name:SHANNON, SAMUEL T
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:SHANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N 6TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4119
Mailing Address - Country:US
Mailing Address - Phone:318-737-7201
Mailing Address - Fax:318-737-7693
Practice Address - Street 1:403 N 6TH ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4119
Practice Address - Country:US
Practice Address - Phone:318-737-7201
Practice Address - Fax:318-737-7693
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1407106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist