Provider Demographics
NPI:1710425467
Name:SHINE, KIERAN M (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KIERAN
Middle Name:M
Last Name:SHINE
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GEORGIA AVE
Mailing Address - Street 2:APT. 6A
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-6222
Mailing Address - Country:US
Mailing Address - Phone:845-649-4871
Mailing Address - Fax:
Practice Address - Street 1:1 GEORGIA AVE
Practice Address - Street 2:APT. 6A
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-6222
Practice Address - Country:US
Practice Address - Phone:845-649-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017966-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist