Provider Demographics
NPI:1477648947
Name:O HAIRE, SHANNON (MSSA BA)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:O HAIRE
Suffix:
Gender:F
Credentials:MSSA BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 HOLLAND RD.
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-891-9808
Mailing Address - Fax:419-891-0688
Practice Address - Street 1:1605 HOLLAND RD.
Practice Address - Street 2:SUITE A-4
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-891-9808
Practice Address - Fax:419-891-0688
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0004856104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOHSW25891Medicare ID - Type UnspecifiedEXPIRED - LACK OF USE