Provider Demographics
NPI:1194173708
Name:LEWIS, SHANNON M (CADC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SW ANKENY RD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-9702
Mailing Address - Country:US
Mailing Address - Phone:515-289-2272
Mailing Address - Fax:515-289-0126
Practice Address - Street 1:501 SW ANKENY RD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9702
Practice Address - Country:US
Practice Address - Phone:515-289-2272
Practice Address - Fax:515-289-0126
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)