Provider Demographics
NPI:1558722280
Name:SHANNON, BRIAN (MA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 NW QUINCE CT
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7657
Mailing Address - Country:US
Mailing Address - Phone:541-581-0394
Mailing Address - Fax:
Practice Address - Street 1:1133 NW WALL ST STE 6
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1962
Practice Address - Country:US
Practice Address - Phone:541-581-0394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7238101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty