Provider Demographics
NPI:1881210938
Name:PIECK, SHANNON REED (CRS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:REED
Last Name:PIECK
Suffix:
Gender:F
Credentials:CRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CENTURY BLVD STE 307
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3692
Mailing Address - Country:US
Mailing Address - Phone:615-425-0220
Mailing Address - Fax:
Practice Address - Street 1:1020 W LACKAWANNA AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-2052
Practice Address - Country:US
Practice Address - Phone:570-904-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA11807175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11807OtherSTATE LICENSE