Healthcare Provider Details

I. General information

NPI: 1891844924
Provider Name (Legal Business Name): SHANNON DENISE MCCULLOCH-BENSON M.A.ED., AAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY
SEATTLE WA
98122-5229
US

IV. Provider business mailing address

1600 E OLIVE ST SOUND MENTAL HEALTH
SEATTLE WA
98122-2735
US

V. Phone/Fax

Practice location:
  • Phone: 206-302-2600
  • Fax: 206-302-2610
Mailing address:
  • Phone: 206-302-2200
  • Fax: 206-302-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60120647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: