Provider Demographics
NPI:1215471842
Name:IKONNE, SHANAZ
Entity type:Individual
Prefix:
First Name:SHANAZ
Middle Name:
Last Name:IKONNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17005 CASANOVA AVE
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-4876
Mailing Address - Country:US
Mailing Address - Phone:469-626-9085
Mailing Address - Fax:
Practice Address - Street 1:1021 RANCH ROAD 620 S STE B
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5611
Practice Address - Country:US
Practice Address - Phone:469-626-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional