Provider Demographics
NPI:1801039656
Name:CASPERSEN, SHANNON GULLIVER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:GULLIVER
Last Name:CASPERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:ALEXANDRA
Other - Last Name:GULLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:70 EAST 96TH STREET
Mailing Address - Street 2:#4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128
Mailing Address - Country:US
Mailing Address - Phone:646-397-4680
Mailing Address - Fax:
Practice Address - Street 1:980 MADISON AVENUE
Practice Address - Street 2:SUITE # 207
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075
Practice Address - Country:US
Practice Address - Phone:646-397-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY259217-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program