Provider Demographics
NPI:1780789677
Name:JOHNSON, SHANNON HUDSON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:HUDSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:COURTNEY
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1926 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212
Mailing Address - Country:US
Mailing Address - Phone:614-481-3432
Mailing Address - Fax:614-538-1656
Practice Address - Street 1:5151 REED RD
Practice Address - Street 2:BUILDING C SUITE 128 CENTRAL OHIO BEHAVIORAL MEDICINE I
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220
Practice Address - Country:US
Practice Address - Phone:614-538-8300
Practice Address - Fax:614-538-1656
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOHIOPSYCHOLOGIST5986103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical