Provider Demographics
NPI:1063048957
Name:STARR, SHANNON G (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:G
Last Name:STARR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 THE 25 WAY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-816-2902
Mailing Address - Fax:
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-702-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-08300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker