Provider Demographics
NPI:1780286088
Name:SHANNON, KATIE LYNN (LCAT, LCPC, LPC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LCAT, LCPC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LOMBARD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5703
Mailing Address - Country:US
Mailing Address - Phone:315-681-7958
Mailing Address - Fax:
Practice Address - Street 1:919 WINTON RD S STE 316
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1633
Practice Address - Country:US
Practice Address - Phone:315-681-7958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016675101YP2500X
MECC6353101YM0800X
NY002452221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health