1306872650 NPI number — BOBBIE H SHANNON LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306872650 NPI number — BOBBIE H SHANNON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
BOBBIE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306872650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRYON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28782-0202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-457-6315
Provider Business Mailing Address Fax Number:
828-859-2225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2143 WARRIOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRYON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28782-5571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-457-6315
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5692 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 2220 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 186133 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1406T . This is a "NVML BCBSNC GRP # 015HF" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 461853 . This is a "MHN TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P1425 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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