Provider Demographics
NPI:1063230936
Name:SHANNON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SHANNON
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 1:21302 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:STONY CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:23882-3751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21302 SUSSEX DRIVE STONY CREEK,
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:VA
Practice Address - Zip Code:23882
Practice Address - Country:US
Practice Address - Phone:434-245-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-570100103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool