Provider Demographics
NPI:1427318104
Name:ERISMAN, SHANNON MARIE (PHD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ERISMAN
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 1:502 BULLOCKS POINT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-3504
Mailing Address - Country:US
Mailing Address - Phone:401-626-4823
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6351
Practice Address - Fax:401-455-6698
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical