Provider Demographics
NPI:1437794583
Name:SIMON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CHURCH POINT
Mailing Address - State:LA
Mailing Address - Zip Code:70525-2506
Mailing Address - Country:US
Mailing Address - Phone:281-299-1383
Mailing Address - Fax:
Practice Address - Street 1:209 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6256
Practice Address - Country:US
Practice Address - Phone:337-942-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2022-02-24
Deactivation Date:2019-12-10
Deactivation Code:
Reactivation Date:2022-02-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator