Provider Demographics
NPI:1255868493
Name:BROTHERS, SHANNON L
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE # 5021
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-5278
Mailing Address - Fax:513-636-2511
Practice Address - Street 1:3333 BURNET AVE ML3015
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-4522
Practice Address - Country:US
Practice Address - Phone:513-636-4336
Practice Address - Fax:513-636-7756
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08036103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist