Provider Demographics
NPI:1528448271
Name:BLACK, SHANNON TRICE (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:TRICE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MANAKIN RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2252
Mailing Address - Country:US
Mailing Address - Phone:804-305-4642
Mailing Address - Fax:804-556-3624
Practice Address - Street 1:1900 MANAKIN RD STE G
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2252
Practice Address - Country:US
Practice Address - Phone:804-305-4642
Practice Address - Fax:804-556-3624
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health