Provider Demographics
NPI:1366747842
Name:MOORE, SHANNON LEIGH (LCSW)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:LEIGH
Last Name:MOORE
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 1:800 S CHURCH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4154
Mailing Address - Country:US
Mailing Address - Phone:870-277-4357
Mailing Address - Fax:870-292-3603
Practice Address - Street 1:800 S CHURCH ST STE 103
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4154
Practice Address - Country:US
Practice Address - Phone:870-277-4357
Practice Address - Fax:870-292-3603
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7953-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical