Provider Demographics
NPI:1225137219
Name:SHANNON, KATHLEEN MARIE (LISW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:930 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5007
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:513-873-1567
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0003968-SUPV104100000X
OHI0003968104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSHSW18564Medicare ID - Type Unspecified