Basic Information
| Provider Information | |||||||||
| NPI: | 1902022841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASSADY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1316 SOMERVILLE RD SE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356014305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562607361 | ||||||||
| FaxNumber: | 2563410747 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 HOSPITAL STREET | ||||||||
| Address2: | |||||||||
| City: | MOULTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563556105 | ||||||||
| FaxNumber: | 2563410747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 051532124 | 01 | AL | BCBS OF AL PROVIDER # | OTHER |