Provider Demographics
NPI:1609007129
Name:SHEA, MAUREEN T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:T
Last Name:SHEA
Suffix:
Gender:F
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:P.O. BOX 5221
Mailing Address - Street 2:856 ROUTE 25A
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-7006
Mailing Address - Country:US
Mailing Address - Phone:631-929-0691
Mailing Address - Fax:
Practice Address - Street 1:586 RTE. 25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-7006
Practice Address - Country:US
Practice Address - Phone:631-929-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01653218Medicaid