MEDICARE: SHANNON NICOLE MARTIN 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	75007	TX

General Provider Information

NPI Number	:	1679047690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON NICOLE MARTIN LPC

Provider Business Mailing Address
First Line	:	346 CYPRESSWOOD DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-5910
Country	:	US
Telephone Number	:	646-241-9968
Fax Number	:

Provider Business Practice Location Address
First Line	:	7676 HILLMONT ST STE 204
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-6469
Country	:	US
Telephone Number	:	978-400-3016
Fax Number	:

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

Provider Enumeration Date	:	01/12/2019
Last Update Date	:	09/25/2019

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