Provider Demographics
NPI:1548925209
Name:SMITH, SHANNON RAQUEL (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAQUEL
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2534 HIGHWAY 590 W
Mailing Address - Street 2:
Mailing Address - City:SEMINARY
Mailing Address - State:MS
Mailing Address - Zip Code:39479-8946
Mailing Address - Country:US
Mailing Address - Phone:601-470-8108
Mailing Address - Fax:601-879-6301
Practice Address - Street 1:140 MAYFAIR RD STE 700
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1616
Practice Address - Country:US
Practice Address - Phone:601-470-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC93291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical