Provider Demographics
NPI:1396907028
Name:COUSINEAU, SHANNON (LCSW, LICSW)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CASSIDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:476 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2783
Mailing Address - Country:US
Mailing Address - Phone:401-954-2700
Mailing Address - Fax:
Practice Address - Street 1:476 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2783
Practice Address - Country:US
Practice Address - Phone:401-954-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118149104100000X, 1041C0700X
NCC014799104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA118149OtherSOCIAL WORK LICENSE
NCC014799OtherSOCIAL WORK LICENSE