Provider Demographics
NPI:1740763465
Name:KING, SHANNON M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2784
Mailing Address - Country:US
Mailing Address - Phone:716-867-5301
Mailing Address - Fax:
Practice Address - Street 1:1416 SWEET HOME RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2784
Practice Address - Country:US
Practice Address - Phone:716-867-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical