Provider Demographics
NPI:1437902798
Name:ACKAL, SHANNON FULLER (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:FULLER
Last Name:ACKAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 TULANE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-6865
Mailing Address - Country:US
Mailing Address - Phone:832-563-3038
Mailing Address - Fax:
Practice Address - Street 1:3000 WESLAYAN ST STE 140
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5700
Practice Address - Country:US
Practice Address - Phone:713-804-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33761103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist