Healthcare Provider Details

I. General information

NPI: 1932531894
Provider Name (Legal Business Name): TAYLER K. SHANNON RN MA LPC LCAS NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 LENDEW ST
GREENSBORO NC
27408-7035
US

IV. Provider business mailing address

1821 LENDEW ST
GREENSBORO NC
27408-7035
US

V. Phone/Fax

Practice location:
  • Phone: 336-288-9190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3221
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9688
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number147098
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: