Provider Demographics
NPI:1992101505
Name:SHANNON, TACEY A (LMSW)
Entity type:Individual
Prefix:MRS
First Name:TACEY
Middle Name:A
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PINE ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3502
Mailing Address - Country:US
Mailing Address - Phone:518-745-0079
Mailing Address - Fax:518-745-4291
Practice Address - Street 1:5 PINE ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3502
Practice Address - Country:US
Practice Address - Phone:518-745-0079
Practice Address - Fax:518-745-4291
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-09
Last Update Date:2014-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076489-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker