Basic Information
| Provider Information | |||||||||
| NPI: | 1619151289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLB | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5109 W BROAD ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432281648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142797690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 246 NORTHLAND DR STE 200A | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2007 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I 1440400 S | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0175437 | 05 | OH | MEDICAID |