Provider Demographics
NPI:1578608683
Name:ROZYCKI, SHANNON LEIGH (MSED, PCC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:ROZYCKI
Suffix:
Gender:F
Credentials:MSED, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MAHONING AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-4605
Mailing Address - Country:US
Mailing Address - Phone:330-395-9563
Mailing Address - Fax:
Practice Address - Street 1:318 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-4605
Practice Address - Country:US
Practice Address - Phone:330-395-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE. 0003945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000217911OtherANTHEM