Provider Demographics
NPI:1932945730
Name:LIEBEL, SHANNON JANELLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JANELLE
Last Name:LIEBEL
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 1:19748 DRY CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3961
Mailing Address - Country:US
Mailing Address - Phone:619-246-5206
Mailing Address - Fax:
Practice Address - Street 1:754 NW BROADWAY ST STE 207
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2776
Practice Address - Country:US
Practice Address - Phone:541-668-7558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9433101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional