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General NPI Number Information
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NPI Number | 1124638523
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Entity Type | Individual
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Provider Name | SHANNON DETWILER MA, LMHC
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Gender | Female
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Dates
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Enumeration Date | 07/31/2020
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Last Update Date | 07/31/2020
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Provider Practice Location Address
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Address Line | 2432 CLUBSIDE CT APT 327
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City | PALM HARBOR
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State | FL
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Zip | 34683-1755
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Country | US
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Telephone | 717-557-7337
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Fax |
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Provider Business Mailing Address
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Address Line | 2432 CLUBSIDE CT APT 327
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City | PALM HARBOR
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State | FL
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Zip | 34683-1755
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Country | US
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Telephone | 717-557-7337
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH18125
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License Number State | FL
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