Provider Demographics
NPI:1356565147
Name:SHEA, BRYAN PATRICK (PHD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:PATRICK
Last Name:SHEA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1102
Mailing Address - Country:US
Mailing Address - Phone:315-386-4939
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2212
Practice Address - Country:US
Practice Address - Phone:315-541-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013393-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical