Provider Demographics
NPI:1427612886
Name:BAZELAIS, SHANNON GILLIAN (LPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GILLIAN
Last Name:BAZELAIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TUTTLE ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4636
Mailing Address - Country:US
Mailing Address - Phone:203-832-5661
Mailing Address - Fax:
Practice Address - Street 1:30 OLD KINGS HWY S
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4551
Practice Address - Country:US
Practice Address - Phone:203-883-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003072101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional