Provider Demographics
NPI:1811246168
Name:COSENTINO, SHANNON NOEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NOEL
Last Name:COSENTINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16132 OLD FOREST PT
Mailing Address - Street 2:UNIT 307
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8678
Mailing Address - Country:US
Mailing Address - Phone:847-630-5594
Mailing Address - Fax:
Practice Address - Street 1:805 S CASCADE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4101
Practice Address - Country:US
Practice Address - Phone:719-473-9200
Practice Address - Fax:719-473-9203
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-02
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004379103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical