Healthcare Provider Details

I. General information

NPI: 1790250504
Provider Name (Legal Business Name): SHANNON RUSSELL QMHS/CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5244 W 2ND ST
DAYTON OH
45417-9044
US

IV. Provider business mailing address

5244 W 2ND ST
DAYTON OH
45417-9044
US

V. Phone/Fax

Practice location:
  • Phone: 937-369-9916
  • Fax:
Mailing address:
  • Phone: 937-369-9916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.165915
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: