Basic Information
Provider Information | |||||||||
NPI: | 1710611413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUDSON | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | SHARAI' | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | SHANON | ||||||||
OtherMiddleName: | SHARAI' | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4101 S 4TH ST | ||||||||
Address2: |   | ||||||||
City: | LEAVENWORTH | ||||||||
State: | KS | ||||||||
PostalCode: | 660485014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136822000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4101 S 4TH ST | ||||||||
Address2: |   | ||||||||
City: | LEAVENWORTH | ||||||||
State: | KS | ||||||||
PostalCode: | 660485014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136822000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2022 | ||||||||
LastUpdateDate: | 07/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW12395 | KS | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.