MEDICARE: MS. SHANNON DAWN LOVERN CAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACB.0008112	CO

General Provider Information

NPI Number	:	1578959003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON DAWN LOVERN CAS

Provider Business Mailing Address
First Line	:	3152 STRIKER DR
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81504-4721
Country	:	US
Telephone Number	:	970-275-1649
Fax Number	:

Provider Business Practice Location Address
First Line	:	2956 NORTH AVE STE 6
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81504-3919
Country	:	US
Telephone Number	:	970-275-1649
Fax Number	:

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

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	12/30/2020

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