Healthcare Provider Details

I. General information

NPI: 1518326594
Provider Name (Legal Business Name): SHANNON SHADMAN MSMHC, M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6102 HAMILTON WAY
EASTAMPTON TOWNSHIP NJ
08060-1673
US

IV. Provider business mailing address

436 CORNELL AVE
PEMBERTON NJ
08068-1712
US

V. Phone/Fax

Practice location:
  • Phone: 484-515-6125
  • Fax:
Mailing address:
  • Phone: 484-515-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37AC00286600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00591200
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: