MEDICARE: SHANNON MICK

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	101YM0800X	Mental Health Counselor	PC011843	PA

General Provider Information

NPI Number	:	1427692110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MICK

Provider Business Mailing Address
First Line	:	605 MARKET ST
Second Line	:
City	:	ZELIENOPLE
State	:	PA
Zip	:	16063-1826
Country	:	US
Telephone Number	:	724-664-8212
Fax Number	:

Provider Business Practice Location Address
First Line	:	20530 ROUTE 19
Second Line	:
City	:	CRANBERRY TOWNSHIP
State	:	PA
Zip	:	16066-7518
Country	:	US
Telephone Number	:	412-592-2403
Fax Number	:

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

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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Directions to “ SHANNON MICK ” Practice Location

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