MEDICARE: SHANNON MCKEE DILLON

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	103TC0700X	Clinical Psychologist	61055150	WA
2	103T00000X	Psychologist	31688	CA

General Provider Information

NPI Number	:	1972939866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MCKEE DILLON

Provider Business Mailing Address
First Line	:	2607 FULTON ST
Second Line	:	APARTMENT A
City	:	BERKELEY
State	:	CA
Zip	:	94704-3228
Country	:	US
Telephone Number	:	530-448-2801
Fax Number	:

Provider Business Practice Location Address
First Line	:	2607 FULTON ST
Second Line	:	APARTMENT A
City	:	BERKELEY
State	:	CA
Zip	:	94704
Country	:	US
Telephone Number	:	530-448-2801
Fax Number	:

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

Provider Enumeration Date	:	09/24/2013
Last Update Date	:	06/29/2023

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