Basic Information
| Provider Information | |||||||||
| NPI: | 1578110151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIBBY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | KRISTINA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W MAIN ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | TILTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032765047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 W MAIN ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | TILTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032765047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0000000 | 01 | NH | VA | OTHER |