Provider Demographics
NPI:1063668275
Name:SHANNON, WILLIAM MACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MACK
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 INDIANA ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-3466
Mailing Address - Country:US
Mailing Address - Phone:510-290-6203
Mailing Address - Fax:
Practice Address - Street 1:1207 INDIANA ST APT 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-3466
Practice Address - Country:US
Practice Address - Phone:510-290-6203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY-22103103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist