Provider Demographics
NPI:1619290574
Name:HENRY, SHAWN D
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:D
Last Name:HENRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 NUMBER THREE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367
Mailing Address - Country:US
Mailing Address - Phone:315-376-5958
Mailing Address - Fax:315-376-5953
Practice Address - Street 1:7714 NUMBER THREE RD
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367
Practice Address - Country:US
Practice Address - Phone:315-376-5958
Practice Address - Fax:315-376-5953
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030867-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical