Provider Demographics
NPI:1891797452
Name:SHANNON, JOSEPH W (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:W
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3043
Mailing Address - Country:US
Mailing Address - Phone:614-297-0422
Mailing Address - Fax:614-297-1050
Practice Address - Street 1:1155 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3043
Practice Address - Country:US
Practice Address - Phone:614-297-0422
Practice Address - Fax:614-297-1050
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3402103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S08084Medicare UPIN
OHP00677378Medicare PIN
OHCP05062Medicare PIN
OHCP05061Medicare PIN