Provider Demographics
NPI:1669147609
Name:RIOS, SHANNA RYAN (LCSWA, LCASA)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:RYAN
Last Name:RIOS
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FOGGY RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-8074
Mailing Address - Country:US
Mailing Address - Phone:910-545-1799
Mailing Address - Fax:
Practice Address - Street 1:119 FOGGY RIVER WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-8074
Practice Address - Country:US
Practice Address - Phone:910-545-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27490101YA0400X
NCP0166451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)