Provider Demographics
NPI:1770268641
Name:SULLIVAN, SHANNON MARGARET
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARGARET
Last Name:SULLIVAN
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 1:8993 MCGINTY RD
Mailing Address - Street 2:
Mailing Address - City:NUNDA
Mailing Address - State:NY
Mailing Address - Zip Code:14517-9706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5130 E MAIN STREET RD STE 2
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3444
Practice Address - Country:US
Practice Address - Phone:585-344-1421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker