Healthcare Provider Details

I. General information

NPI: 1881050300
Provider Name (Legal Business Name): SHANNON WATTS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 LYNWOOD DR
NORTH WATERBORO ME
04061-4636
US

IV. Provider business mailing address

201 MARINER WAY # 1009
BIDDEFORD ME
04005-9437
US

V. Phone/Fax

Practice location:
  • Phone: 207-229-6469
  • Fax:
Mailing address:
  • Phone: 207-229-6469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC16979
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: