Provider Demographics
NPI:1689492175
Name:HARRIS, SHANNON IVY (PSYD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:IVY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:IVY
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:STE 2500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2280
Practice Address - Country:US
Practice Address - Phone:317-963-7204
Practice Address - Fax:317-963-7211
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043698A103TC0700X, 103TB0200X
IN20043698B103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300098450Medicaid
IN1104565401OtherANTHEM PTAN