Provider Demographics
NPI:1770932188
Name:VICTOR, SHANNEL
Entity type:Individual
Prefix:
First Name:SHANNEL
Middle Name:
Last Name:VICTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1463
Mailing Address - Country:US
Mailing Address - Phone:302-376-9619
Mailing Address - Fax:
Practice Address - Street 1:417 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1463
Practice Address - Country:US
Practice Address - Phone:302-376-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health