Provider Demographics
NPI:1578089926
Name:SHANAHAN, ISABEL JO
Entity Type:Individual
Prefix:
First Name:ISABEL
Middle Name:JO
Last Name:SHANAHAN
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 1:215 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4840
Mailing Address - Country:US
Mailing Address - Phone:505-310-4619
Mailing Address - Fax:
Practice Address - Street 1:190 N 10TH ST STE 301
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-9317
Practice Address - Country:US
Practice Address - Phone:917-293-4642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health