MEDICARE: SHANNON LATRAY LCPC, LPC, LCMHC

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	101YM0800X	Mental Health Counselor	C7145	OR
2	101YM0800X	Mental Health Counselor	252224	AK
3	101YM0800X	Mental Health Counselor	12837764-6004	UT
4	101YM0800X	Mental Health Counselor	CC6660	ME
5	101YM0800X	Mental Health Counselor	PRC200001490	DC
6	101YM0800X	Mental Health Counselor	37PC00912400	NJ
7	101YM0800X	Mental Health Counselor	13387-MH-CC	MA
8	101YM0800X	Mental Health Counselor	LPC-21627	AZ
9	101YM0800X	Mental Health Counselor	5736	NH
10	101YM0800X	Mental Health Counselor	017983	NY
11	101YM0800X	Mental Health Counselor	BBH-LCPC-LIC-17894	MT

General Provider Information

NPI Number	:	1790431096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LATRAY LCPC, LPC, LCMHC

Provider Business Mailing Address
First Line	:	4134 WYNNE AVE APT C
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-6733
Country	:	US
Telephone Number	:	406-560-2799
Fax Number	:

Provider Business Practice Location Address
First Line	:	4134 WYNNE AVE APT C
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-6733
Country	:	US
Telephone Number	:	406-560-2799
Fax Number	:

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

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	06/25/2026

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