Provider Demographics
NPI:1972153062
Name:PRIDDY, SHANNON (MSW, LSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BUSSNICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:500 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2135
Mailing Address - Country:US
Mailing Address - Phone:908-725-2800
Mailing Address - Fax:
Practice Address - Street 1:500 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2135
Practice Address - Country:US
Practice Address - Phone:908-725-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05911600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0539198Medicaid
NJ7797403Medicaid
NJ0023701Medicaid