Provider Demographics
NPI:1083184717
Name:SHANE, MARIA SUZANNE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:SUZANNE
Last Name:SHANE
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 1:50171 FAIRPOINT MAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-8353
Mailing Address - Country:US
Mailing Address - Phone:740-317-9784
Mailing Address - Fax:
Practice Address - Street 1:1 HALLORAN LN
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950
Practice Address - Country:US
Practice Address - Phone:740-296-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician