1114062833 NPI number — MS. SHANNON COLLEEN DEAN MS, LCPC

Table of content: MS. SHANNON COLLEEN DEAN MS, LCPC (NPI 1114062833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114062833 NPI number — MS. SHANNON COLLEEN DEAN MS, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAN
Provider First Name:
SHANNON
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONAHUE
Provider Other First Name:
SHANNON
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, LCPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114062833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 IL ROUTE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIXON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61021-9118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-284-6611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 IL ROUTE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIXON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61021-9118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-284-6611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2007

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: 101YM0800X , with the licence number:  180005452 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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