Provider Demographics
NPI:1538939194
Name:ROMAN, SHANNON ROSE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:ROMAN
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 1:1409 BOTHAM JEAN BLVD APT 233
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-6817
Mailing Address - Country:US
Mailing Address - Phone:469-396-6079
Mailing Address - Fax:
Practice Address - Street 1:1409 BOTHAM JEAN BLVD APT 233
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-6817
Practice Address - Country:US
Practice Address - Phone:469-396-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor