Provider Demographics
NPI:1720221849
Name:DARK, SHANNON P (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:P
Last Name:DARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:P
Other - Last Name:PIPPIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3550 S NATIONAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7309
Mailing Address - Country:US
Mailing Address - Phone:417-269-9300
Mailing Address - Fax:
Practice Address - Street 1:3550 S NATIONAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7309
Practice Address - Country:US
Practice Address - Phone:417-269-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00859517OtherRAILROAD MEDICARE
MO500410016Medicare PIN
MO167600001Medicare PIN