Provider Demographics
NPI:1427692110
Name:MICK, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MICK
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 1:605 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-1826
Mailing Address - Country:US
Mailing Address - Phone:724-664-8212
Mailing Address - Fax:
Practice Address - Street 1:20530 ROUTE 19
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-7518
Practice Address - Country:US
Practice Address - Phone:412-592-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011843101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health