Provider Demographics
NPI:1487159075
Name:SMALL, SHANNON LEE (CADC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:SMALL
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 STATE ST STE 13B
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1850
Mailing Address - Country:US
Mailing Address - Phone:207-835-5809
Mailing Address - Fax:
Practice Address - Street 1:248 STATE ST STE 13B
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1850
Practice Address - Country:US
Practice Address - Phone:207-835-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC4944101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)