Healthcare Provider Details

I. General information

NPI: 1164553194
Provider Name (Legal Business Name): JANIS A SHANNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 SE FEDERAL HWY #103
STUART FL
34994-4531
US

IV. Provider business mailing address

2440 SE FEDERAL HWY #103
STUART FL
34994-4531
US

V. Phone/Fax

Practice location:
  • Phone: 772-882-8836
  • Fax:
Mailing address:
  • Phone: 772-882-8836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074605-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW0084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: