Provider Demographics
NPI:1124638523
Name:DETWILER, SHANNON (MA, LMHC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DETWILER
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 CLUBSIDE CT APT 327
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1755
Mailing Address - Country:US
Mailing Address - Phone:717-557-7337
Mailing Address - Fax:
Practice Address - Street 1:2432 CLUBSIDE CT APT 327
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1755
Practice Address - Country:US
Practice Address - Phone:717-557-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health