Provider Demographics
NPI:1871070565
Name:DENNIS, SHAWN DYLAN (LCSW)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DYLAN
Last Name:DENNIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DYLAN
Other - Middle Name:
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:10282 PRIVATE ROAD 8829
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-9400
Mailing Address - Country:US
Mailing Address - Phone:417-280-1247
Mailing Address - Fax:870-341-6242
Practice Address - Street 1:410 GOLDSMITH AVE
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-8045
Practice Address - Country:US
Practice Address - Phone:417-280-1247
Practice Address - Fax:870-341-6242
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8780-C1041C0700X
AR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR232264719Medicaid