Provider Demographics
NPI:1114471265
Name:TRAVER, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TRAVER
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 1:415 LOWER MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-2661
Mailing Address - Country:US
Mailing Address - Phone:518-746-2400
Mailing Address - Fax:518-746-2461
Practice Address - Street 1:415 LOWER MAIN ST
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-2661
Practice Address - Country:US
Practice Address - Phone:518-746-2400
Practice Address - Fax:518-746-2461
Is Sole Proprietor?:No
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03001012Medicaid