Provider Demographics
NPI:1891800603
Name:KURTH, SHANNA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:MARIE
Last Name:KURTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N DRIES LN
Mailing Address - Street 2:STE 303
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1265
Mailing Address - Country:US
Mailing Address - Phone:309-686-9005
Mailing Address - Fax:309-686-9020
Practice Address - Street 1:3100 N DRIES LN
Practice Address - Street 2:STE 303
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1265
Practice Address - Country:US
Practice Address - Phone:309-686-9005
Practice Address - Fax:309-686-9020
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004929103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007226636OtherBCBS OF IL
IL212891Medicare ID - Type Unspecified