Provider Demographics
NPI:1902048176
Name:KING, SHANNON MARIE (LCSWC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6112 PALMAS DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6751
Mailing Address - Country:US
Mailing Address - Phone:240-818-9499
Mailing Address - Fax:386-310-3992
Practice Address - Street 1:1690 DUNLAWTON AVE STE 125
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8980
Practice Address - Country:US
Practice Address - Phone:240-818-9499
Practice Address - Fax:386-310-3992
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD156891041C0700X
FLSW 100861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ04FNOtherFLORIDA BLUE
FL023156600Medicaid
FL165897Medicare PIN