Provider Demographics
NPI:1679235170
Name:ROBERTS, SHANNON SAGE (LMHC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:SAGE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 W DALE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3709
Mailing Address - Country:US
Mailing Address - Phone:813-382-5505
Mailing Address - Fax:
Practice Address - Street 1:415 S HYDE PARK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2268
Practice Address - Country:US
Practice Address - Phone:813-254-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19549101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health