Provider Demographics
NPI:1295388080
Name:MOONEY, SHANNON (BEHAVIOR SPECIALIST)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MOONEY
Suffix:
Gender:F
Credentials:BEHAVIOR SPECIALIST
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:376 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4762
Mailing Address - Country:US
Mailing Address - Phone:208-403-1559
Mailing Address - Fax:
Practice Address - Street 1:376 5TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4762
Practice Address - Country:US
Practice Address - Phone:208-403-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-20
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities