Provider Demographics
NPI:1780555920
Name:CHRISTIAN PA, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CHRISTIAN PA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15741 CITRUS GROVE LOOP
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9456
Mailing Address - Country:US
Mailing Address - Phone:253-691-2414
Mailing Address - Fax:
Practice Address - Street 1:187 S BOYD ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3501
Practice Address - Country:US
Practice Address - Phone:253-691-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH283761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty