Provider Demographics
NPI:1043694110
Name:RICHEY, SHANNA
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:RICHEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CAMEL HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1604
Mailing Address - Country:US
Mailing Address - Phone:631-271-5440
Mailing Address - Fax:
Practice Address - Street 1:24 CAMEL HOLLOW RD
Practice Address - Street 2:
Practice Address - City:LLOYD HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11743-1604
Practice Address - Country:US
Practice Address - Phone:631-271-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098812104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker