Provider Demographics
NPI:1740474816
Name:SHANNON, TAKESHA MONIQUE (LPC)
Entity type:Individual
Prefix:
First Name:TAKESHA
Middle Name:MONIQUE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ENERGY CENTER BLVD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5827
Mailing Address - Country:US
Mailing Address - Phone:205-764-0850
Mailing Address - Fax:205-331-4082
Practice Address - Street 1:700 ENERGY CENTER BLVD
Practice Address - Street 2:SUITE 407
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5827
Practice Address - Country:US
Practice Address - Phone:205-764-0850
Practice Address - Fax:205-331-4082
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2536101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-99846OtherBLUE CROSS BLUE SHIELD OF ALABAMA