Provider Demographics
NPI:1639729825
Name:THOMAS, SHANNON E (CDCA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17837 TR 1182
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812
Mailing Address - Country:US
Mailing Address - Phone:740-294-7192
Mailing Address - Fax:
Practice Address - Street 1:17837 TOWNSHIP ROAD 1182
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-9340
Practice Address - Country:US
Practice Address - Phone:740-294-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OH177469101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty