Provider Demographics
NPI:1255196705
Name:SERAGUSA, SHANNON (LPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SERAGUSA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2402
Mailing Address - Country:US
Mailing Address - Phone:908-354-7474
Mailing Address - Fax:
Practice Address - Street 1:40 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2402
Practice Address - Country:US
Practice Address - Phone:908-352-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00772800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional