Provider Demographics
NPI:1861072597
Name:ROBINSON, SHANNON JENILE (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JENILE
Last Name:ROBINSON
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 1:201 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-1116
Mailing Address - Country:US
Mailing Address - Phone:757-945-9457
Mailing Address - Fax:
Practice Address - Street 1:201 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-1116
Practice Address - Country:US
Practice Address - Phone:757-945-9457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040128101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904012810Medicaid