Healthcare Provider Details

I. General information

NPI: 1508704537
Provider Name (Legal Business Name): SHANNON MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 AVENUE U UNIT 290147
BROOKLYN NY
11229-7504
US

IV. Provider business mailing address

2302 AVENUE U UNIT 290147
BROOKLYN NY
11229-7504
US

V. Phone/Fax

Practice location:
  • Phone: 347-708-0777
  • Fax: 347-464-0013
Mailing address:
  • Phone: 347-708-0777
  • Fax: 347-464-0013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: