Healthcare Provider Details

I. General information

NPI: 1962033779
Provider Name (Legal Business Name): MARY JANE SHOONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FULTON AVE
CINCINNATI OH
45206-2504
US

IV. Provider business mailing address

5506 TIMBER CT
MILFORD OH
45150-1789
US

V. Phone/Fax

Practice location:
  • Phone: 513-961-4663
  • Fax:
Mailing address:
  • Phone: 513-284-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM.1900099
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: