Healthcare Provider Details

I. General information

NPI: 1205843596
Provider Name (Legal Business Name): SCOTT SHANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 COLLAND DR
FORT COLLINS CO
80525-6929
US

IV. Provider business mailing address

7603 COLLAND DR
FORT COLLINS CO
80525-6929
US

V. Phone/Fax

Practice location:
  • Phone: 970-663-2686
  • Fax: 970-663-1226
Mailing address:
  • Phone: 970-663-2686
  • Fax: 970-663-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number31090
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier31090
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerMD
# 2
Identifier3573
Identifier TypeOTHER
Identifier State
Identifier IssuerAM BOARD OF PSYH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: