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NPI Code Detail

MEDICARE: SHANNON MARIE HAWORTH

MEDICARE: SHANNON MARIE HAWORTH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1124363361
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANNON MARIE HAWORTH
Provider Business Mailing Address
First Line : 1109 WELBORNE DR
Second Line :
City : RICHMOND
State : VA
Zip : 23229-5651
Country : US
Telephone Number : 402-801-2206
Fax Number :
Provider Business Practice Location Address
First Line : 4100 PRICE CLUB BLVD
Second Line :
City : MIDLOTHIAN
State : VA
Zip : 23112-3379
Country : US
Telephone Number : 804-674-8888
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/28/2012
Last Update Date : 11/28/2012

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