Shannon L Martin, LPC LIC # 2018028478

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

2018028478 Issued in MO

Practice address

1000 Hospital Rd
Waynesville, MO 65583-2634

Phone

(573) 774-5353

Fax

(573) 774-2907

NPI assigned

May 4, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Woodridge of Missouri, Inc.

  dba Perimeter Behavioral of Missouri

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Waynesville, MO
  • NPI 1174662720
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620086400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620086400000",
    "number": "1144803420",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "284 HILL N DALE DR",
            "city": "CAMDENTON",
            "state": "MO",
            "postal_code": "650205101",
            "telephone_number": "417-501-9560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 HOSPITAL RD",
            "city": "WAYNESVILLE",
            "state": "MO",
            "postal_code": "655832634",
            "telephone_number": "573-774-5353",
            "fax_number": "573-774-2907"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MARTIN",
        "first_name": "SHANNON",
        "middle_name": "L",
        "credential": "LPC LIC # 2018028478",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-05-04",
        "last_updated": "2021-05-04",
        "certification_date": "2021-05-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "MO",
            "license": "2018028478",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1174662720",
            "state": "MO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "shanldial@gmail.com",
            "affiliation": "Y",
            "affiliationName": "WoodRidge of Missouri, Inc.",
            "address_1": "1000 Hospital Rd",
            "city": "Waynesville",
            "state": "MO",
            "country_code": "US",
            "postal_code": "655832634",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Kira Ann Longoria, MS ED, LPC
• Michelle Marie Love
• Paul W. Lowe, PA-C
• Ma. Teresa Sison Enciso PT. PC. Corp (Therapy Partners)
• Susan Armstrong Marino, LPC
• Christopher McCarty, OPTICIAN
• Rebecca Lynn McClain, FNP-C
• Holly Rachelle McCormick
• Agathe McEachern, FNP
• Medicom, Inc

• Professional Counselor in Waynesville, MO
• Providers in Waynesville, MO by specialty
• Professional Counselor in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 4, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.