Provider Demographics
NPI:1457441735
Name:YOUNG, SHANNON L (LMFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:YOUNG
Other - Last Name:TREDENNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:2 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 206A
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2288
Mailing Address - Country:US
Mailing Address - Phone:203-417-1908
Mailing Address - Fax:203-791-9094
Practice Address - Street 1:2 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 206A
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2288
Practice Address - Country:US
Practice Address - Phone:203-417-1908
Practice Address - Fax:203-791-9094
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000748106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004187614Medicaid
CT004187614Medicaid