Healthcare Provider Details

I. General information

NPI: 1588131270
Provider Name (Legal Business Name): SHANNON BEAVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 106
GRAMPIAN PA
16838-0106
US

IV. Provider business mailing address

1144 SUGAR CAMP RD
MAHAFFEY PA
15757-5940
US

V. Phone/Fax

Practice location:
  • Phone: 833-668-6861
  • Fax:
Mailing address:
  • Phone: 814-592-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: