Provider Demographics
NPI:1134963440
Name:THEOBALD, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:795 E KIOWA AVE UNIT 1471
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-5060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 E KIOWA AVE UNIT 1471
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-5060
Practice Address - Country:US
Practice Address - Phone:720-428-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool