MEDICARE: SHANNON R MARRIOTT M.A., LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	61175	TX

General Provider Information

NPI Number	:	1265643894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON R MARRIOTT M.A., LPC

Provider Business Mailing Address
First Line	:	5945 W PARKER RD
Second Line	:	APT. 434
City	:	PLANO
State	:	TX
Zip	:	75093-7755
Country	:	US
Telephone Number	:	972-932-5995
Fax Number	:

Provider Business Practice Location Address
First Line	:	4031 W PLANO PKWY
Second Line	:	SUITE 211
City	:	PLANO
State	:	TX
Zip	:	75093-5619
Country	:	US
Telephone Number	:	214-351-3490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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