Provider Demographics
NPI:1790250504
Name:RUSSELL, SHANNON (QMHS/CDCA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:QMHS/CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5244 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-9044
Mailing Address - Country:US
Mailing Address - Phone:937-369-9916
Mailing Address - Fax:
Practice Address - Street 1:5244 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9044
Practice Address - Country:US
Practice Address - Phone:937-369-9916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165915171M00000X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator