Individual
TIM SHANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSYD
Contact information
Practice address
405 KAYS DR STE C, NORMAL, IL 61761-1979
(309) 664-3130
(309) 664-3528
Mailing address
405 KAYS DR STE C, NORMAL, IL 61761-1979
(309) 664-3130
(309) 664-3528
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
071004783
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DP5951
RR MEDICARE GROUP
—
01
—
IL2613
MEDICARE GROUP PTAN
IL
01
—
P00820811
RR MEDICARE INDIVIDUAL
—
Enumeration date
09/25/2006
Last updated
05/09/2011
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