Basic Information
Provider Information | |||||||||
NPI: | 1275626996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERKINS | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRIFFITH | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 525 E MARKET ST | ||||||||
Address2: | PO BOX 2090 | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443041619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3309968603 | ||||||||
FaxNumber: | 3309968695 | ||||||||
Practice Location | |||||||||
Address1: | 95 ARCH ST | ||||||||
Address2: | SUITE 260 | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443041437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303756590 | ||||||||
FaxNumber: | 3303756593 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 12/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 5907 | OH | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 2373015 | 05 | OH |   | MEDICAID | CP28704 | 01 | OH | MEDICARE ID | OTHER |