Provider Demographics
NPI:1023084027
Name:SHANNON, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1727
Mailing Address - Country:US
Mailing Address - Phone:716-961-9900
Mailing Address - Fax:716-961-9911
Practice Address - Street 1:3980 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1727
Practice Address - Country:US
Practice Address - Phone:716-961-9900
Practice Address - Fax:716-961-9911
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0253661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical