Provider Demographics
NPI:1104604032
Name:WALSH, SHANNON JONELL (LMHCA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JONELL
Last Name:WALSH
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 HOHLIER LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7311
Mailing Address - Country:US
Mailing Address - Phone:706-992-3236
Mailing Address - Fax:
Practice Address - Street 1:515 N GREEN ST STE 401
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-2115
Practice Address - Country:US
Practice Address - Phone:317-852-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88002099A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health