Provider Demographics
NPI:1407001258
Name:SHANNON, CARLY BLAKE (LPC)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:BLAKE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 HOLY SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-4237
Mailing Address - Country:US
Mailing Address - Phone:512-897-2709
Mailing Address - Fax:
Practice Address - Street 1:4144 N CENTRAL EXPY STE 850
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3226
Practice Address - Country:US
Practice Address - Phone:512-956-6463
Practice Address - Fax:866-653-5142
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional