MEDICARE: SHANNON LEE ANN STANCER LAC

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	1647	KS

General Provider Information

NPI Number	:	1841832128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LEE ANN STANCER LAC

Provider Business Mailing Address
First Line	:	166 HOLIDAY DR
Second Line	:
City	:	LINN VALLEY
State	:	KS
Zip	:	66040-5455
Country	:	US
Telephone Number	:	913-337-1433
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 W 8TH ST
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-2404
Country	:	US
Telephone Number	:	785-893-2473
Fax Number	:

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

Provider Enumeration Date	:	10/08/2019
Last Update Date	:	10/08/2019

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