Provider Demographics
NPI:1104166305
Name:HUFF, SHANNON COLLEEN (EDS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:COLLEEN
Last Name:HUFF
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494
Mailing Address - Country:US
Mailing Address - Phone:715-323-6856
Mailing Address - Fax:
Practice Address - Street 1:531 3RD ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494
Practice Address - Country:US
Practice Address - Phone:715-323-6856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI885-58103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist