Provider Demographics
NPI:1538712377
Name:JOHANSON, SHANNON NICOLE (ED S)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WHETHERBURN DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8868
Mailing Address - Country:US
Mailing Address - Phone:412-443-0867
Mailing Address - Fax:
Practice Address - Street 1:3970 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44121-2223
Practice Address - Country:US
Practice Address - Phone:216-242-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21733887103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool