Provider Demographics
NPI:1609579317
Name:GANLEY, SHANNON VICTORIA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VICTORIA
Last Name:GANLEY
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 1:243 W 76TH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-8245
Mailing Address - Country:US
Mailing Address - Phone:860-819-9488
Mailing Address - Fax:
Practice Address - Street 1:252 JAVA ST STE 331
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-5558
Practice Address - Country:US
Practice Address - Phone:860-819-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health