=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558619684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON BROWN LPC, LCDC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2012
-----------------------------------------------------
Last Update Date | 11/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1855 LONGMIRE RD
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-648-5379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10223 CUDE CEMETERY RD
-----------------------------------------------------
City | WILLIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77318-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-524-8044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 11752
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 67759
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------