Provider Demographics
NPI:1942562749
Name:RUEB, SHANNON (MS, ED)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:RUEB
Suffix:
Gender:F
Credentials:MS, ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1115
Mailing Address - Country:US
Mailing Address - Phone:631-804-1814
Mailing Address - Fax:
Practice Address - Street 1:231 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-1115
Practice Address - Country:US
Practice Address - Phone:631-804-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY360868174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110606Medicaid