Healthcare Provider Details

I. General information

NPI: 1144714585
Provider Name (Legal Business Name): SHANNON LARANCE LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 W CHISUM TRL
PHOENIX AZ
85085-8657
US

IV. Provider business mailing address

610 E BELL RD STE 2-132
PHOENIX AZ
85022-2383
US

V. Phone/Fax

Practice location:
  • Phone: 602-405-2261
  • Fax:
Mailing address:
  • Phone: 602-405-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCSW-20062
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP012375
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: