Provider Demographics
NPI:1417508987
Name:STANLEY, SHANNON (CDCA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STANLEY
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-1158
Mailing Address - Country:US
Mailing Address - Phone:234-678-5941
Mailing Address - Fax:234-678-3403
Practice Address - Street 1:878 W MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44303-1158
Practice Address - Country:US
Practice Address - Phone:234-678-5941
Practice Address - Fax:234-678-3403
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0001449175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0001449OtherOHIO MENTAL HEALTH AND ADDICTION SERVICES (OMHAS)