Healthcare Provider Details

I. General information

NPI: 1033035217
Provider Name (Legal Business Name): SHANNON IRENE SANTORO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 4TH AVE APT 3D
BROOKLYN NY
11232-1048
US

IV. Provider business mailing address

639 4TH AVE APT 3D
BROOKLYN NY
11232-1048
US

V. Phone/Fax

Practice location:
  • Phone: 845-214-7462
  • Fax:
Mailing address:
  • Phone: 845-214-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number027137
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: