Provider Demographics
NPI:1629895669
Name:DI VIRGILIO, SHANNON ROSE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:DI VIRGILIO
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 1:324 NIGHT SAIL DR N APT 301
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-0010
Mailing Address - Country:US
Mailing Address - Phone:706-889-0383
Mailing Address - Fax:
Practice Address - Street 1:324 NIGHT SAIL DR N APT 301
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-0010
Practice Address - Country:US
Practice Address - Phone:706-889-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health