Healthcare Provider Details

I. General information

NPI: 1770908196
Provider Name (Legal Business Name): MR. CORY R. SHUTTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PHILLIPS ST
MASSENA NY
13662-2016
US

IV. Provider business mailing address

80 STATE HIGHWAY 310 STE 1
CANTON NY
13617-1436
US

V. Phone/Fax

Practice location:
  • Phone: 315-764-8076
  • Fax: 315-764-8079
Mailing address:
  • Phone: 315-386-2167
  • Fax: 315-386-2435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006804
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: