Provider Demographics
NPI:1114454550
Name:HARPER, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HARPER
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 1:2 CLARA BARTON DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3472
Mailing Address - Country:US
Mailing Address - Phone:182-625-5511
Mailing Address - Fax:518-262-6111
Practice Address - Street 1:2 CLARA BARTON DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3472
Practice Address - Country:US
Practice Address - Phone:182-625-5511
Practice Address - Fax:518-262-6111
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023459103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical