MEDICARE: SHANNON R. PRESTON LCSW

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	1041C0700X	Clinical Social Worker	LC13787	ME

General Provider Information

NPI Number	:	1659692333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON R. PRESTON LCSW

Provider Business Mailing Address
First Line	:	901 WASHINGTON AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-2737
Country	:	US
Telephone Number	:	207-871-1200
Fax Number	:	207-283-2850

Provider Business Practice Location Address
First Line	:	901 WASHINGTON AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-2737
Country	:	US
Telephone Number	:	207-871-1200
Fax Number	:	207-283-2850

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

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	05/04/2015

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