Provider Demographics
NPI:1316098528
Name:COOK, SHANNON MONIECE (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MONIECE
Last Name:COOK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34921 US HIGHWAY 19 N STE 260
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1969
Mailing Address - Country:US
Mailing Address - Phone:727-225-3736
Mailing Address - Fax:
Practice Address - Street 1:34921 US HIGHWAY 19 N STE 200
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-255-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7486103TC0700X
FLPY 7486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
59424OtherBCBSFL
FLAC879Medicare PIN