Provider Demographics
NPI:1871974238
Name:TROUT, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TROUT
Suffix:
Gender:F
Credentials:
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 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-994-5486
Mailing Address - Fax:
Practice Address - Street 1:16170 MAIN ST STE F
Practice Address - Street 2:
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457-7603
Practice Address - Country:US
Practice Address - Phone:707-994-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator