Basic Information
| Provider Information | |||||||||
| NPI: | 1154058501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'SULLIVAN | ||||||||
| FirstName: | SHANNON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROAD PKWY APT 5E | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453447034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2094 ALBANY POST RD | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105481454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147374400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1986922 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.