Provider Demographics
NPI:1659118826
Name:SHANNON, PAYTON ASHLEY (COUNSELOR IN TRAINEE)
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:ASHLEY
Last Name:SHANNON
Suffix:
Gender:F
Credentials:COUNSELOR IN TRAINEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 BOARDMAN CANFIELD RD STE L1
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4370
Mailing Address - Country:US
Mailing Address - Phone:330-330-8655
Mailing Address - Fax:
Practice Address - Street 1:16 EVANS AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1621
Practice Address - Country:US
Practice Address - Phone:330-330-8655
Practice Address - Fax:330-330-8657
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.187159101YA0400X
OHC.2405953-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)