Provider Demographics
NPI:1851050223
Name:SHANNON, EMILY ALYSSA
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ALYSSA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 AMERICUS MINOR DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2175
Mailing Address - Country:US
Mailing Address - Phone:321-305-9576
Mailing Address - Fax:
Practice Address - Street 1:3200 S HIAWASSEE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6317
Practice Address - Country:US
Practice Address - Phone:407-490-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL195283106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician