Provider Demographics
NPI:1841655719
Name:LEIST, SHANNON (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LEIST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8006 VISTA PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-7733
Mailing Address - Country:US
Mailing Address - Phone:812-777-5759
Mailing Address - Fax:812-725-7865
Practice Address - Street 1:2627 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2536
Practice Address - Country:US
Practice Address - Phone:812-944-1550
Practice Address - Fax:812-725-7865
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007313A101YM0800X
IN34008294A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health