Provider Demographics
NPI:1972839660
Name:SHANNON, TRACY E (PSYD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:E
Last Name:SHANNON
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-3830
Mailing Address - Fax:614-293-4870
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1229
Practice Address - Country:US
Practice Address - Phone:614-293-3830
Practice Address - Fax:614-293-4870
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015476103TC0700X
OHP.7251103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical