Healthcare Provider Details

I. General information

NPI: 1407109408
Provider Name (Legal Business Name): SHANNON MARIE KROENKE MSW, LCSW, MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 8TH ST STE 110
VANCOUVER WA
98660-3294
US

IV. Provider business mailing address

101 E 8TH ST STE 110
VANCOUVER WA
98660-3294
US

V. Phone/Fax

Practice location:
  • Phone: 360-524-2126
  • Fax:
Mailing address:
  • Phone: 360-524-2126
  • Fax: 360-953-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW60887254
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60887254
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberLW60887254
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: