Healthcare Provider Details

I. General information

NPI: 1285376715
Provider Name (Legal Business Name): SHANNON BLACK DOTSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DORCHESTER SQ N STE 102
WESTERVILLE OH
43081-7305
US

IV. Provider business mailing address

100 DORCHESTER SQ N STE 102
WESTERVILLE OH
43081-7305
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-8262
  • Fax:
Mailing address:
  • Phone: 614-890-8262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2203928-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2205152
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: