Provider Demographics
NPI:1407956758
Name:SHANNON, TIM (PSYD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KAYS DR STE C
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1979
Mailing Address - Country:US
Mailing Address - Phone:309-664-3130
Mailing Address - Fax:309-664-3528
Practice Address - Street 1:405 KAYS DR STE C
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1979
Practice Address - Country:US
Practice Address - Phone:309-664-3130
Practice Address - Fax:309-664-3528
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004783103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
DP5951OtherRR MEDICARE GROUP
P00820811OtherRR MEDICARE INDIVIDUAL
IL0533210001Medicare NSC
IL204523Medicare PIN
ILIL2613OtherMEDICARE GROUP PTAN
ILR17515Medicare UPIN