Provider Demographics
NPI:1053520882
Name:MINNICK, SHANNON MICHELLE (MA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:MINNICK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:510 E EMMAUS AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5918
Mailing Address - Country:US
Mailing Address - Phone:610-737-3680
Mailing Address - Fax:
Practice Address - Street 1:1620 BROADWAY
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-3904
Practice Address - Country:US
Practice Address - Phone:610-799-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009484101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional