Provider Demographics
NPI:1992085831
Name:SHANNON, THEODORE PAUL (PHD, MS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:PAUL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 PROPRIETORS RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3230
Mailing Address - Country:US
Mailing Address - Phone:614-785-1115
Mailing Address - Fax:614-785-0095
Practice Address - Street 1:1035 PROPRIETORS RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-3230
Practice Address - Country:US
Practice Address - Phone:614-785-1115
Practice Address - Fax:614-785-0095
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 0700153101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor