Healthcare Provider Details

I. General information

NPI: 1891520854
Provider Name (Legal Business Name): SHANNON RYAN LMSW
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 NEW BRITAIN RD STE C
BERLIN CT
06037-5306
US

IV. Provider business mailing address

33 FAIRFIELD PL
BEACON FALLS CT
06403-1436
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 203-523-9263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9860
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: