Provider Demographics
NPI:1912153289
Name:DEETS, SHANNON LEN (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEN
Last Name:DEETS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEN
Other - Last Name:RHODES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:18278 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-8380
Mailing Address - Country:US
Mailing Address - Phone:814-807-0487
Mailing Address - Fax:888-538-2885
Practice Address - Street 1:18278 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-8380
Practice Address - Country:US
Practice Address - Phone:814-807-0487
Practice Address - Fax:888-538-2885
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004908101YM0800X
PAPS018703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024531890002Medicaid