Provider Demographics
NPI:1194453654
Name:CRANDALL, SHANNON MARIE MCDERMOTT (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE MCDERMOTT
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 RUTH ANN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8020
Mailing Address - Country:US
Mailing Address - Phone:636-439-1931
Mailing Address - Fax:
Practice Address - Street 1:311 RUTH ANN DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8020
Practice Address - Country:US
Practice Address - Phone:636-439-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160139481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical