=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801020573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON NICOLE WALKER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2009
-----------------------------------------------------
Last Update Date | 06/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 JUNCTION DR W SUITE 6
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-710-4123
-----------------------------------------------------
Fax | 618-731-4082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 JUNCTION DR W SUITE 6
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-710-4123
-----------------------------------------------------
Fax | 618-731-4082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071.007664
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------