Provider Demographics
NPI:1801427133
Name:WISCHUSEN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WISCHUSEN
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 1:261 BROOME ST APT 2H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4507
Mailing Address - Country:US
Mailing Address - Phone:908-347-7055
Mailing Address - Fax:
Practice Address - Street 1:261 BROOME ST APT 2H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4507
Practice Address - Country:US
Practice Address - Phone:908-347-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency