Provider Demographics
NPI:1477691384
Name:OWENS, SHANE GREGORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:GREGORY
Last Name:OWENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 COMMACK RD
Mailing Address - Street 2:SUITE LL 2
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-6021
Mailing Address - Country:US
Mailing Address - Phone:631-462-5554
Mailing Address - Fax:631-420-2089
Practice Address - Street 1:283 COMMACK RD
Practice Address - Street 2:SUITE LL 2
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-6021
Practice Address - Country:US
Practice Address - Phone:631-462-5554
Practice Address - Fax:631-420-2089
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015938103T00000X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVM5471OtherNSLIJ EMPIRE BCBS
NY9383228OtherPHCS PID
NY028279OtherVMC BEHAVIORAL HEALTHCARE
NYVM5471Medicare ID - Type Unspecified