Provider Demographics
NPI:1962282848
Name:SHANNON, DOMIQUE (MSW, SUPERVISEE)
Entity type:Individual
Prefix:
First Name:DOMIQUE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MSW, SUPERVISEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ARBORETUM PL STE 502
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3473
Mailing Address - Country:US
Mailing Address - Phone:804-887-2990
Mailing Address - Fax:
Practice Address - Street 1:300 ARBORETUM PL
Practice Address - Street 2:SUITE 502
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3473
Practice Address - Country:US
Practice Address - Phone:804-382-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0906013267104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker