Provider Demographics
NPI:1700590874
Name:SHANNON, TASHA (LCPC)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OAK DR STE B
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5635
Mailing Address - Country:US
Mailing Address - Phone:618-972-2866
Mailing Address - Fax:
Practice Address - Street 1:1941 FRANK SCOTT PKWY E
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7387
Practice Address - Country:US
Practice Address - Phone:618-972-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.014589101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional