Provider Demographics
NPI:1831939354
Name:HINES, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HINES
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 1:1715 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3291
Mailing Address - Country:US
Mailing Address - Phone:830-445-9379
Mailing Address - Fax:
Practice Address - Street 1:1715 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3291
Practice Address - Country:US
Practice Address - Phone:830-445-9379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool