Provider Demographics
NPI:1568836088
Name:SHANNON, MAX (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6637 114TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-6433
Mailing Address - Country:US
Mailing Address - Phone:707-537-5754
Mailing Address - Fax:
Practice Address - Street 1:6637 114TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-6433
Practice Address - Country:US
Practice Address - Phone:503-766-3690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61019392103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical