Healthcare Provider Details

I. General information

NPI: 1144956210
Provider Name (Legal Business Name): SHANNON TALLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 LUCY CORR CT
CHESTERFIELD VA
23832-6657
US

IV. Provider business mailing address

PO BOX 92
CHESTERFIELD VA
23832-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-1227
  • Fax:
Mailing address:
  • Phone: 804-748-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701011592
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: