Provider Demographics
NPI:1356025399
Name:RUSSELL, SHANNON DAVID (LCPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAVID
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59104-3321
Mailing Address - Country:US
Mailing Address - Phone:406-200-8518
Mailing Address - Fax:406-794-0206
Practice Address - Street 1:1645 PARKHILL DR STE 1
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-3067
Practice Address - Country:US
Practice Address - Phone:406-200-8518
Practice Address - Fax:406-794-0206
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT63533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional