Provider Demographics
NPI:1740951961
Name:ROSS, SHANON RAE (LMSW)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:RAE
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 OAKRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5952
Mailing Address - Country:US
Mailing Address - Phone:903-452-7677
Mailing Address - Fax:
Practice Address - Street 1:100 W HAWKINS PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1816
Practice Address - Country:US
Practice Address - Phone:903-663-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69127104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker