Provider Demographics
NPI:1144722067
Name:HERRON, SHANNON RENE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2212
Mailing Address - Country:US
Mailing Address - Phone:423-573-6836
Mailing Address - Fax:
Practice Address - Street 1:10434 JACKSON OAKS WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3293
Practice Address - Country:US
Practice Address - Phone:865-730-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN58561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5856OtherLCSW