Provider Demographics
NPI:1861169286
Name:MARCUM, SHANNON MARIE BRIEASHIA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE BRIEASHIA
Last Name:MARCUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S 9TH AVE APT 117
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-2057
Mailing Address - Country:US
Mailing Address - Phone:815-719-2208
Mailing Address - Fax:
Practice Address - Street 1:1606 HUNT DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2192
Practice Address - Country:US
Practice Address - Phone:815-719-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical