Provider Demographics
NPI:1235158023
Name:HURST, SHANNON R (MSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:HURST
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 TANTAMOUNT LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-3540
Mailing Address - Country:US
Mailing Address - Phone:937-776-7810
Mailing Address - Fax:
Practice Address - Street 1:6404 TANTAMOUNT LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3540
Practice Address - Country:US
Practice Address - Phone:937-776-7810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 06000221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical