Provider Demographics
NPI:1194193565
Name:YOUNG, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:YOUNG
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 1:110 E 177TH ST
Mailing Address - Street 2:1J
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-5918
Mailing Address - Country:US
Mailing Address - Phone:917-346-5896
Mailing Address - Fax:
Practice Address - Street 1:110 E 177TH STREET
Practice Address - Street 2:1 J
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:UM
Practice Address - Phone:917-346-5896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst