Healthcare Provider Details

I. General information

NPI: 1679485064
Provider Name (Legal Business Name): SHANNON SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 ROUTE 55 STE F
LAGRANGEVILLE NY
12540-5057
US

IV. Provider business mailing address

1133 ROUTE 55 STE F
LAGRANGEVILLE NY
12540-5057
US

V. Phone/Fax

Practice location:
  • Phone: 845-232-0703
  • Fax:
Mailing address:
  • Phone: 845-232-0703
  • Fax:

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: