MEDICARE: SHANNON NICOLE JOHANSON ED. S.

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	103TS0200X	School Psychologist	21733887	OH

General Provider Information

NPI Number	:	1538712377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON NICOLE JOHANSON ED. S.

Provider Business Mailing Address
First Line	:	212 WHETHERBURN DR
Second Line	:
City	:	WEXFORD
State	:	PA
Zip	:	15090-8868
Country	:	US
Telephone Number	:	412-443-0867
Fax Number	:

Provider Business Practice Location Address
First Line	:	3970 MAYFIELD RD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44121-2223
Country	:	US
Telephone Number	:	216-242-6324
Fax Number	:

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

Provider Enumeration Date	:	07/21/2019
Last Update Date	:	07/21/2019

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