Provider Demographics
NPI:1396202826
Name:BISHOP, SHANNON (CG60935285)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BISHOP
Suffix:
Gender:F
Credentials:CG60935285
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 KARR AVE
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550-1818
Mailing Address - Country:US
Mailing Address - Phone:360-602-2957
Mailing Address - Fax:
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-3016
Practice Address - Country:US
Practice Address - Phone:360-602-2957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60935285101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor