Healthcare Provider Details

I. General information

NPI: 1730887233
Provider Name (Legal Business Name): SHANNON TIARA PERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17579 WARWICK BLVD
NEWPORT NEWS VA
23603-1343
US

IV. Provider business mailing address

PO BOX 224
SUNBURY NC
27979-0224
US

V. Phone/Fax

Practice location:
  • Phone: 757-888-0400
  • Fax:
Mailing address:
  • Phone: 252-339-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014615
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: