MEDICARE: MRS. DEBORAH L SHANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW2551	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z6252	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1376592527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBORAH L SHANNON

Provider Business Mailing Address
First Line	:	108 JAMAICA DR
Second Line	:
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-3213
Country	:	US
Telephone Number	:	407-920-2344
Fax Number	:	321-799-1109

Provider Business Practice Location Address
First Line	:	1980 N ATLANTIC AVE
Second Line	:	SUITE 515
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5213
Country	:	US
Telephone Number	:	321-501-2328
Fax Number	:	321-799-1109

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	06/11/2015

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Directions to “ MRS. DEBORAH L SHANNON ” Practice Location

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