Provider Demographics
NPI:1962046615
Name:CARLSON, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CARLSON
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 1:2683 ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8577
Mailing Address - Country:US
Mailing Address - Phone:630-733-9108
Mailing Address - Fax:
Practice Address - Street 1:2683 ROUTE 34
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8577
Practice Address - Country:US
Practice Address - Phone:630-733-9108
Practice Address - Fax:630-912-4242
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional