Basic Information
| Provider Information | |||||||||
| NPI: | 1639592843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEITCH | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3913 SPRING CIRCLE DR E | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775849385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817886807 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 N GORDON ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775112718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815850000 | ||||||||
| FaxNumber: | 2815850080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2014 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 66956 | TX | Y | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 66956 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.