Provider Demographics
NPI:1548872740
Name:ANDERSON, SHANNEN (PSYD)
Entity type:Individual
Prefix:
First Name:SHANNEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNEN
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:951 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-1701
Mailing Address - Country:US
Mailing Address - Phone:760-883-0565
Mailing Address - Fax:
Practice Address - Street 1:386 STANLEY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-6009
Practice Address - Country:US
Practice Address - Phone:508-679-5222
Practice Address - Fax:508-673-3182
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008539103TC0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor