Provider Demographics
NPI:1063658094
Name:CRONN, SHANNON (MED, MA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CRONN
Suffix:
Gender:F
Credentials:MED, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 E VILLA MARIA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-1581
Mailing Address - Country:US
Mailing Address - Phone:480-221-9208
Mailing Address - Fax:
Practice Address - Street 1:10101 E THOMPSON PEAK PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-3300
Practice Address - Country:US
Practice Address - Phone:480-484-1507
Practice Address - Fax:480-484-1501
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1359374103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool