Healthcare Provider Details

I. General information

NPI: 1740676659
Provider Name (Legal Business Name): SHANNA PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 VISTA DEL MONTE PL
RIO COMMUNITIES NM
87002-9515
US

IV. Provider business mailing address

1103 VISTA DEL MONTE PL
RIO COMMUNITIES NM
87002-9515
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-8965
  • Fax:
Mailing address:
  • Phone: 505-450-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0206361
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: