Provider Demographics
NPI:1851929525
Name:MARTINEAU, SHANNON (QMHS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTINEAU
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-6955
Mailing Address - Country:US
Mailing Address - Phone:419-242-9955
Mailing Address - Fax:
Practice Address - Street 1:701 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-6955
Practice Address - Country:US
Practice Address - Phone:419-242-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056676Medicaid