Healthcare Provider Details

I. General information

NPI: 1447042379
Provider Name (Legal Business Name): SHANNON JOHN COLWIN MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 LANDMARK PL STE 210
MADISON WI
53713-4200
US

IV. Provider business mailing address

2590 GLADEVIEW RD
COTTAGE GROVE WI
53527-9531
US

V. Phone/Fax

Practice location:
  • Phone: 855-458-4966
  • Fax: 855-458-4966
Mailing address:
  • Phone: 920-251-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8390226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: