Provider Demographics
NPI:1831065044
Name:WANAMAKER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WANAMAKER
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 1:1479 LOUISA ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1633
Mailing Address - Country:US
Mailing Address - Phone:717-804-4878
Mailing Address - Fax:888-830-8571
Practice Address - Street 1:1479 LOUISA ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1633
Practice Address - Country:US
Practice Address - Phone:717-804-4878
Practice Address - Fax:888-830-8571
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA340850103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty