Provider Demographics
NPI:1740972694
Name:SHANNON, MAXINE ELIZABETH (LAC)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:ELIZABETH
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 PARK AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-1768
Mailing Address - Country:US
Mailing Address - Phone:908-322-9623
Mailing Address - Fax:
Practice Address - Street 1:551 PARK AVE STE 7
Practice Address - Street 2:
Practice Address - City:SCOTCH PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07076-1768
Practice Address - Country:US
Practice Address - Phone:908-322-9623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00717200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health