Provider Demographics
NPI:1730312356
Name:SMALL, SHANNON NATSUKO
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NATSUKO
Last Name:SMALL
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 1:50 DEKALB AVE
Mailing Address - Street 2:S2
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 DEKALB AVE
Practice Address - Street 2:S2
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1445
Practice Address - Country:US
Practice Address - Phone:808-384-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-30
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016436225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics