Provider Demographics
NPI:1881172286
Name:SHANNON, DENNIS EDWARDS
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:EDWARDS
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3135
Mailing Address - Country:US
Mailing Address - Phone:703-799-2861
Mailing Address - Fax:703-799-2822
Practice Address - Street 1:8119 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3135
Practice Address - Country:US
Practice Address - Phone:703-799-2861
Practice Address - Fax:703-799-2822
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007762101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health