Provider Demographics
NPI:1255842464
Name:SYMONS, SHACKOLA SAMANTHA (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:SHACKOLA
Middle Name:SAMANTHA
Last Name:SYMONS
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4132
Mailing Address - Country:US
Mailing Address - Phone:718-614-2093
Mailing Address - Fax:
Practice Address - Street 1:481 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-6324
Practice Address - Country:US
Practice Address - Phone:914-355-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006456-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health