Provider Demographics
NPI:1356465033
Name:WASSAM, SHANNON DEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEE
Last Name:WASSAM
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:PO BOX 513
Mailing Address - Street 2:308 E SMITH
Mailing Address - City:SMITHTON
Mailing Address - State:MO
Mailing Address - Zip Code:65350-0513
Mailing Address - Country:US
Mailing Address - Phone:660-343-3681
Mailing Address - Fax:660-343-5871
Practice Address - Street 1:308 E SMITH ST
Practice Address - Street 2:
Practice Address - City:SMITHTON
Practice Address - State:MO
Practice Address - Zip Code:65350-1079
Practice Address - Country:US
Practice Address - Phone:660-343-3681
Practice Address - Fax:660-343-5871
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities