Provider Demographics
NPI:1063054047
Name:REARDON, SHANNON KRISTIN
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:KRISTIN
Last Name:REARDON
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 1:320 NASSAU RD APT 112
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4359
Mailing Address - Country:US
Mailing Address - Phone:631-521-1926
Mailing Address - Fax:
Practice Address - Street 1:5 DAKOTA DR
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1107
Practice Address - Country:US
Practice Address - Phone:631-521-1926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016409225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist