Provider Demographics
NPI:1679595300
Name:BLACK, SHANNON L (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 ASHLAND ROAD
Mailing Address - Street 2:PO BOX 533
Mailing Address - City:CERESCO
Mailing Address - State:NE
Mailing Address - Zip Code:68017
Mailing Address - Country:US
Mailing Address - Phone:402-432-0745
Mailing Address - Fax:
Practice Address - Street 1:6120 HAVELOCK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68507-1278
Practice Address - Country:US
Practice Address - Phone:402-432-0745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical