Provider Demographics
NPI:1386315323
Name:TOMBLIN, SHANNON (CDCA184535)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TOMBLIN
Suffix:
Gender:F
Credentials:CDCA184535
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1403
Mailing Address - Country:US
Mailing Address - Phone:740-237-4981
Mailing Address - Fax:
Practice Address - Street 1:323 MARION PIKE STE 1
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:877-325-2816
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
OHCDCA.180524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484876Medicaid