Provider Demographics
NPI:1447553441
Name:LENZE, SHANNON NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICOLE
Last Name:LENZE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-286-1700
Mailing Address - Fax:314-970-9094
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:STE 2600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1700
Practice Address - Fax:314-970-9094
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016949103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494217409Medicaid