Provider Demographics
NPI:1477023091
Name:SHIN, FANNIE
Entity type:Individual
Prefix:
First Name:FANNIE
Middle Name:
Last Name:SHIN
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 1:7 CENTURY HILL DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2113
Mailing Address - Country:US
Mailing Address - Phone:518-641-1119
Mailing Address - Fax:
Practice Address - Street 1:7 CENTURY HILL DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2113
Practice Address - Country:US
Practice Address - Phone:518-641-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002452103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07638604Medicaid