Provider Demographics
NPI:1730795220
Name:BURKE, SHANNON MARIE (LICSW, PIP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:LICSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 SANDNER CT APT C
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5648
Mailing Address - Country:US
Mailing Address - Phone:229-288-5985
Mailing Address - Fax:
Practice Address - Street 1:1713 6TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0001
Practice Address - Country:US
Practice Address - Phone:205-975-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4485C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical