Healthcare Provider Details

I. General information

NPI: 1336651413
Provider Name (Legal Business Name): SHANNON LANCELLOTTI L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BRANT AVE STE 3
CLARK NJ
07066-1548
US

IV. Provider business mailing address

17 FAIRVIEW RD
CLARK NJ
07066-2942
US

V. Phone/Fax

Practice location:
  • Phone: 732-713-2484
  • Fax:
Mailing address:
  • Phone: 732-713-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04602400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: