Provider Demographics
NPI:1184346181
Name:SHANNON, BENJAMIN (BA, EXP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:BA, EXP
Other - Prefix:MR
Other - First Name:BENJAMIN
Other - Middle Name:LOUIS
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3261 COLONY VISTA LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3261 COLONY VISTA LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-2157
Practice Address - Country:US
Practice Address - Phone:614-859-9584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSM594493103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist