Healthcare Provider Details

I. General information

NPI: 1629895669
Provider Name (Legal Business Name): SHANNON ROSE DI VIRGILIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 NIGHT SAIL DR N APT 301
MEMPHIS TN
38103-0010
US

IV. Provider business mailing address

324 NIGHT SAIL DR N APT 301
MEMPHIS TN
38103-0010
US

V. Phone/Fax

Practice location:
  • Phone: 706-889-0383
  • Fax:
Mailing address:
  • Phone: 706-889-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7013
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: