Provider Demographics
NPI:1912454372
Name:GOSS, SHANNON (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:GOSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27045 BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:OLMSTED TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44138-1103
Mailing Address - Country:US
Mailing Address - Phone:440-427-6214
Mailing Address - Fax:
Practice Address - Street 1:27045 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:OLMSTED TWP
Practice Address - State:OH
Practice Address - Zip Code:44138-1103
Practice Address - Country:US
Practice Address - Phone:440-427-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist