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NPI Code Detail

MEDICARE: MRS. CARLY BLAKE SHANNON LPC

MEDICARE: MRS. CARLY BLAKE SHANNON 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
1101YP2500XProfessional Counselor62456TX

General Provider Information

NPI Number : 1407001258
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CARLY BLAKE SHANNON LPC
Provider Business Mailing Address
First Line : 5109 HOLY SPRINGS RD
Second Line :
City : DENTON
State : TX
Zip : 76207-4237
Country : US
Telephone Number : 512-897-2709
Fax Number :
Provider Business Practice Location Address
First Line : 4144 N CENTRAL EXPY STE 850
Second Line :
City : DALLAS
State : TX
Zip : 75204-3226
Country : US
Telephone Number : 512-956-6463
Fax Number : 866-653-5142
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/20/2008
Last Update Date : 09/18/2025

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Directions to “ MRS. CARLY BLAKE SHANNON LPC” Practice Location

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