Provider Demographics
NPI:1245870443
Name:MEVISSEN, SHANA SUSANNE
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:SUSANNE
Last Name:MEVISSEN
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 1:713 TROY SCHENECTADY RD STE 224
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 AMHURST AVE # 3
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:NY
Practice Address - Zip Code:12831-1834
Practice Address - Country:US
Practice Address - Phone:517-778-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty