Provider Demographics
NPI:1023603479
Name:BRENNAN, SHANNON MARIE (SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 COLIN DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1523
Mailing Address - Country:US
Mailing Address - Phone:631-682-9111
Mailing Address - Fax:
Practice Address - Street 1:122 COLIN DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-1523
Practice Address - Country:US
Practice Address - Phone:631-682-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14242330235Z00000X
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist