Provider Demographics
NPI:1972954584
Name:SHANAHAN, SALLY KING (DED)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:KING
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 QUEEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-1441
Mailing Address - Country:US
Mailing Address - Phone:484-888-9841
Mailing Address - Fax:
Practice Address - Street 1:803 QUEEN DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1441
Practice Address - Country:US
Practice Address - Phone:484-888-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017852103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool