Provider Demographics
NPI:1801020573
Name:WALKER, SHANNON NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICOLE
Last Name:WALKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:BAUGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9 JUNCTION DR W
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2931
Mailing Address - Country:US
Mailing Address - Phone:618-710-4123
Mailing Address - Fax:618-731-4082
Practice Address - Street 1:9 JUNCTION DR W
Practice Address - Street 2:SUITE 6
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2931
Practice Address - Country:US
Practice Address - Phone:618-710-4123
Practice Address - Fax:618-731-4082
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007664103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical