Provider Demographics
NPI:1255672564
Name:EZELL, SHANNA DENISE (MHP)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:DENISE
Last Name:EZELL
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 8TH ST APT D
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1656
Mailing Address - Country:US
Mailing Address - Phone:618-524-3653
Mailing Address - Fax:618-524-4769
Practice Address - Street 1:206 W 5TH ST
Practice Address - Street 2:APT. D
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1810
Practice Address - Country:US
Practice Address - Phone:618-524-9368
Practice Address - Fax:618-524-9551
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health