Healthcare Provider Details

I. General information

NPI: 1376817262
Provider Name (Legal Business Name): SHANNON O'DONNELL LMSW, LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON BOOTH

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 DEZARAE APT 3
SAN ANTONIO TX
78253-5986
US

IV. Provider business mailing address

1401 DEZARAE APT 3
SAN ANTONIO TX
78253-5986
US

V. Phone/Fax

Practice location:
  • Phone: 210-530-4167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12064
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103360
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: