Provider Demographics
NPI:1780099077
Name:MOTTER, SHANNON MICHELLE (LADC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:MOTTER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2307
Mailing Address - Country:US
Mailing Address - Phone:402-558-7088
Mailing Address - Fax:402-558-7133
Practice Address - Street 1:130 N. 39TH ST.
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131
Practice Address - Country:US
Practice Address - Phone:402-558-7088
Practice Address - Fax:402-558-7133
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1068101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)