Provider Demographics
NPI:1366162539
Name:MARTIN, SHANNON (MA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4721 S CLIFF AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6969
Mailing Address - Country:US
Mailing Address - Phone:816-608-1958
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:14155 92 HWY
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-8907
Practice Address - Country:US
Practice Address - Phone:816-916-7228
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician