Provider Demographics
NPI:1417185638
Name:MOTT, SHANNON KAYE (CRADC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KAYE
Last Name:MOTT
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 S PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1847
Mailing Address - Country:US
Mailing Address - Phone:618-664-1455
Mailing Address - Fax:618-664-1744
Practice Address - Street 1:503 S PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1847
Practice Address - Country:US
Practice Address - Phone:618-664-1455
Practice Address - Fax:618-664-1744
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24675101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)