Provider Demographics
NPI:1508371261
Name:KOHNKE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KOHNKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MECHANIC ST STE 302
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2419
Mailing Address - Country:US
Mailing Address - Phone:508-792-5400
Mailing Address - Fax:508-831-0074
Practice Address - Street 1:585 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1906
Practice Address - Country:US
Practice Address - Phone:508-762-1931
Practice Address - Fax:781-890-2624
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor