Provider Demographics
NPI:1558546978
Name:SHANNON, DONALD EUGENE (CAP #4011)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:EUGENE
Last Name:SHANNON
Suffix:
Gender:M
Credentials:CAP #4011
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7145 NE 199TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:CITRA
Mailing Address - State:FL
Mailing Address - Zip Code:32113-2809
Mailing Address - Country:US
Mailing Address - Phone:352-595-7746
Mailing Address - Fax:
Practice Address - Street 1:7145 NE 199TH STREET RD
Practice Address - Street 2:
Practice Address - City:CITRA
Practice Address - State:FL
Practice Address - Zip Code:32113-2809
Practice Address - Country:US
Practice Address - Phone:352-595-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)