Healthcare Provider Details

I. General information

NPI: 1366162539
Provider Name (Legal Business Name): SHANNON MARTIN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MARTIN

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 92 HWY
PLATTE CITY MO
64079-8907
US

IV. Provider business mailing address

4721 S CLIFF AVE STE 103
INDEPENDENCE MO
64055-6969
US

V. Phone/Fax

Practice location:
  • Phone: 816-916-7228
  • Fax: 800-687-5070
Mailing address:
  • Phone: 816-608-1958
  • Fax: 800-687-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: