Provider Demographics
NPI:1982236014
Name:O'CONNOR, SHANNON CHRISTINE (LCDC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:CHRISTINE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 S LAMAR BLVD APT 3718
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7960
Mailing Address - Country:US
Mailing Address - Phone:845-216-6735
Mailing Address - Fax:
Practice Address - Street 1:3838 RAWLINS ST APT 313
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4250
Practice Address - Country:US
Practice Address - Phone:845-216-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX15159101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty