Provider Demographics
NPI:1902022841
Name:JOHNSON, SHANNON LEE (MA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEE
Other - Last Name:CASSADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1316 SOMERVILLE RD SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4305
Mailing Address - Country:US
Mailing Address - Phone:256-260-7361
Mailing Address - Fax:256-341-0747
Practice Address - Street 1:317 HOSPITAL STREET
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650
Practice Address - Country:US
Practice Address - Phone:256-355-6105
Practice Address - Fax:256-341-0747
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051532124OtherBCBS OF AL PROVIDER #