Provider Demographics
NPI:1063668275
Name:SHANNON, WILLIAM MACK (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MACK
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 16TH ST UNIT 401
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2180
Mailing Address - Country:US
Mailing Address - Phone:619-817-9309
Mailing Address - Fax:
Practice Address - Street 1:625 16TH ST UNIT 401
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2180
Practice Address - Country:US
Practice Address - Phone:510-290-6203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22103103TC0700X
CAPSY-22103103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical