Provider Demographics
NPI:1699874198
Name:SHANNON, KELLY (PHD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
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:PO BOX 120041
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-9241
Mailing Address - Country:US
Mailing Address - Phone:210-279-1516
Mailing Address - Fax:210-733-0141
Practice Address - Street 1:102 E MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2946
Practice Address - Country:US
Practice Address - Phone:210-279-1516
Practice Address - Fax:210-733-0141
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3034103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH00088RY01OtherBCBS - TX
TX035931704Medicaid
TXH00088RY01OtherBCBS - TX