Provider Demographics
NPI:1932515962
Name:CARROLL, SHANNON EUGENE
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:EUGENE
Last Name:CARROLL
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 1:726 BROADWAY
Mailing Address - Street 2:SUITE 471
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9502
Mailing Address - Country:US
Mailing Address - Phone:212-998-4780
Mailing Address - Fax:212-995-4096
Practice Address - Street 1:726 BROADWAY
Practice Address - Street 2:SUITE 471
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9502
Practice Address - Country:US
Practice Address - Phone:212-998-4780
Practice Address - Fax:212-995-4096
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401730363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health