Healthcare Provider Details

I. General information

NPI: 1700549862
Provider Name (Legal Business Name): SHANNON ALEXANDRA VAN BEEST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 LINCOLN WAY UNIT 214
AMES IA
50014-3461
US

IV. Provider business mailing address

4415 LINCOLN WAY UNIT 214
AMES IA
50014-3461
US

V. Phone/Fax

Practice location:
  • Phone: 712-461-1736
  • Fax:
Mailing address:
  • Phone: 712-461-1736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number108114
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: