Provider Demographics
NPI:1063406387
Name:SHANNON, NANCY (LSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 633762
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3762
Mailing Address - Country:US
Mailing Address - Phone:800-594-1876
Mailing Address - Fax:
Practice Address - Street 1:1200 RALSTON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1396
Practice Address - Country:US
Practice Address - Phone:419-783-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0004427104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000142646OtherANTHEM
OHSHSW75801Medicare ID - Type Unspecified
S66075Medicare UPIN