Provider Demographics
NPI:1750605432
Name:GUTWEIN, SHANNON P (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:P
Last Name:GUTWEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1868
Mailing Address - Country:US
Mailing Address - Phone:307-732-1161
Mailing Address - Fax:307-732-1191
Practice Address - Street 1:640 E BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-732-1616
Practice Address - Fax:307-732-1191
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
WYLCSW-9221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator