Provider Demographics
NPI:1104411719
Name:CARL, SHANNON W (LPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:W
Last Name:CARL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 OLD HEWITT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6599
Mailing Address - Country:US
Mailing Address - Phone:254-214-3397
Mailing Address - Fax:
Practice Address - Street 1:209 OLD HEWITT RD STE 3
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6599
Practice Address - Country:US
Practice Address - Phone:254-214-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health