Healthcare Provider Details

I. General information

NPI: 1508538562
Provider Name (Legal Business Name): SHANNON STEPHENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2435
US

IV. Provider business mailing address

300 MENAUL BLVD NW STE A
ALBUQUERQUE NM
87107-1347
US

V. Phone/Fax

Practice location:
  • Phone: 505-525-3649
  • Fax:
Mailing address:
  • Phone: 505-525-9649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2023-0286
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: