Provider Demographics
NPI:1578835971
Name:SMITH, SHANNON (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 SAINT ROSE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7784
Mailing Address - Country:US
Mailing Address - Phone:725-290-1238
Mailing Address - Fax:
Practice Address - Street 1:2520 SAINT ROSE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7784
Practice Address - Country:US
Practice Address - Phone:725-290-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0003348101YM0800X
NVCP0033101YM0800X
NV0033101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health