Provider Demographics
NPI:1144035403
Name:SMOOT, SHANNON (MA, LPCC17567,PPSC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMOOT
Suffix:
Gender:X
Credentials:MA, LPCC17567,PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 GLEN AVE APT 111
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4907
Mailing Address - Country:US
Mailing Address - Phone:341-688-1809
Mailing Address - Fax:
Practice Address - Street 1:77 GLEN AVE APT 111
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4907
Practice Address - Country:US
Practice Address - Phone:341-688-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
CALPCC17567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool