Provider Demographics
NPI:1316781107
Name:NOLAN, SHANNON NICOLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:NOLAN
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 1:40 HAIGHT AVE # 831
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5960
Mailing Address - Country:US
Mailing Address - Phone:845-549-8961
Mailing Address - Fax:
Practice Address - Street 1:21-23 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-562-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP128414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist