Provider Demographics
NPI:1790678183
Name:SON, SHIN AE
Entity type:Individual
Prefix:
First Name:SHIN AE
Middle Name:
Last Name:SON
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 1:20114 ROCKY HILL RD APT G1
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3082
Mailing Address - Country:US
Mailing Address - Phone:718-313-7590
Mailing Address - Fax:
Practice Address - Street 1:20114 ROCKY HILL RD APT G1
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3082
Practice Address - Country:US
Practice Address - Phone:718-313-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004320103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst