Individual
KELLY SHANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
102 E MULBERRY AVE, SAN ANTONIO, TX 78212-2946
(210) 279-1516
(210) 733-0141
Mailing address
PO BOX 120041, SAN ANTONIO, TX 78212-9241
(210) 279-1516
(210) 733-0141
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
2-3034
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
035931704
—
TX
01
—
H00088RY01
BCBS - TX
TX
Enumeration date
09/21/2006
Last updated
03/24/2009
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