Provider Demographics
NPI:1972676963
Name:SUMRALL, SHANNON LARRY (LPC)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:LARRY
Last Name:SUMRALL
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 SCR 3
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39168-5066
Mailing Address - Country:US
Mailing Address - Phone:504-648-7036
Mailing Address - Fax:601-729-9002
Practice Address - Street 1:234 HIGHWAY 28 W
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39443-7845
Practice Address - Country:US
Practice Address - Phone:504-224-7651
Practice Address - Fax:601-729-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19687101YP2500X
MS3254101YP2500X
LA3109101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175767601Medicaid
TX175767601Medicaid