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: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S ALMA SCHOOL RD STE A203
MESA AZ
85210-3066
US

IV. Provider business mailing address

1930 S ALMA SCHOOL RD STE A203
MESA AZ
85210-3066
US

V. Phone/Fax

Practice location:
  • Phone: 480-343-0808
  • Fax:
Mailing address:
  • Phone: 480-343-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1281717
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-24982
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: