Healthcare Provider Details

I. General information

NPI: 1548796410
Provider Name (Legal Business Name): SHANNON WELCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3542 MONTGOMERY HWY
DOTHAN AL
36303-2165
US

IV. Provider business mailing address

PO BOX 1245
DOTHAN AL
36302-1245
US

V. Phone/Fax

Practice location:
  • Phone: 334-803-8667
  • Fax:
Mailing address:
  • Phone: 334-803-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3893C
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: