Healthcare Provider Details

I. General information

NPI: 1003746801
Provider Name (Legal Business Name): SHANNON HALLSTROM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 E VINE AVE
MESA AZ
85208-2346
US

IV. Provider business mailing address

9025 E VINE AVE
MESA AZ
85208-2346
US

V. Phone/Fax

Practice location:
  • Phone: 480-380-3868
  • Fax:
Mailing address:
  • Phone: 480-380-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1281717
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: