Provider Demographics
NPI:1154058501
Name:O'SULLIVAN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'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 1:1 BROAD PKWY APT 5E
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-3715
Mailing Address - Country:US
Mailing Address - Phone:845-344-7034
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1454
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1986922104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker