Provider Demographics
NPI:1982394649
Name:AZZALINA, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:AZZALINA
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 1:100 CROWNE POINT PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-5427
Mailing Address - Country:US
Mailing Address - Phone:513-743-7628
Mailing Address - Fax:
Practice Address - Street 1:2172A US HIGHWAY 127 N
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-9289
Practice Address - Country:US
Practice Address - Phone:937-336-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003098175T00000X
101YA0400X, 106S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator