MEDICARE: BENJAMIN SHANNON BA, EXP

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
1	103T00000X	Psychologist	SM594493	OH

General Provider Information

NPI Number	:	1184346181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN SHANNON BA, EXP

Provider Business Mailing Address
First Line	:	3261 COLONY VISTA LN
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-2157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3261 COLONY VISTA LN
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-2157
Country	:	US
Telephone Number	:	614-859-9584
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2022
Last Update Date	:	09/15/2022

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