Healthcare Provider Details

I. General information

NPI: 1891075149
Provider Name (Legal Business Name): SHANNON M FLYNN MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RAVINIA CT
SHOREWOOD IL
60404-9444
US

IV. Provider business mailing address

1111 RAVINIA CT
SHOREWOOD IL
60404-9444
US

V. Phone/Fax

Practice location:
  • Phone: 815-585-1019
  • Fax:
Mailing address:
  • Phone: 815-585-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number279884
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180012013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: