Provider Demographics
NPI:1174674725
Name:SHEA, ROSE M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:M
Last Name:SHEA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 IVY PL
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-4933
Mailing Address - Country:US
Mailing Address - Phone:607-217-4966
Mailing Address - Fax:
Practice Address - Street 1:420 IVY PL
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-4933
Practice Address - Country:US
Practice Address - Phone:607-217-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050633-1101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional