Healthcare Provider Details

I. General information

NPI: 1134963440
Provider Name (Legal Business Name): SHANNON THEOBALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON GREENE

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 E KIOWA AVE UNIT 1471
ELIZABETH CO
80107-5060
US

IV. Provider business mailing address

795 E KIOWA AVE UNIT 1471
ELIZABETH CO
80107-5060
US

V. Phone/Fax

Practice location:
  • Phone: 720-952-7103
  • Fax:
Mailing address:
  • Phone: 720-952-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: