Provider Demographics
NPI:1891370540
Name:SHANNON POCIECHA PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHANNON POCIECHA PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:POCIECHA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-804-8086
Mailing Address - Street 1:455 BURR OAK DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7503
Mailing Address - Country:US
Mailing Address - Phone:847-804-8086
Mailing Address - Fax:
Practice Address - Street 1:1625 BETHANY RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3124
Practice Address - Country:US
Practice Address - Phone:779-777-7335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty