Provider Demographics
NPI:1740676659
Name:PARKER, SHANNA
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 VISTA DEL MONTE PL
Mailing Address - Street 2:
Mailing Address - City:RIO COMMUNITIES
Mailing Address - State:NM
Mailing Address - Zip Code:87002-9515
Mailing Address - Country:US
Mailing Address - Phone:505-450-8965
Mailing Address - Fax:
Practice Address - Street 1:1103 VISTA DEL MONTE PL
Practice Address - Street 2:
Practice Address - City:RIO COMMUNITIES
Practice Address - State:NM
Practice Address - Zip Code:87002-9515
Practice Address - Country:US
Practice Address - Phone:505-450-8965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0206361101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional