Provider Demographics
NPI:1962761361
Name:VICENTE, SHANNYN S (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNYN
Middle Name:S
Last Name:VICENTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 BROADWAY STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5728
Mailing Address - Country:US
Mailing Address - Phone:210-501-9869
Mailing Address - Fax:
Practice Address - Street 1:5108 BROADWAY STE 220
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5728
Practice Address - Country:US
Practice Address - Phone:210-501-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC135771041C0700X
TX649621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical