Provider Demographics
NPI:1912412024
Name:COLLINS, SHANNON HAZEL (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:HAZEL
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:HAZEL
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3535 82ND ST APT 51
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5127
Mailing Address - Country:US
Mailing Address - Phone:646-894-1388
Mailing Address - Fax:
Practice Address - Street 1:18 EAST 16TH STREET
Practice Address - Street 2:SUITE 503, OFFICE 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:646-543-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022392103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical