Healthcare Provider Details

I. General information

NPI: 1245870443
Provider Name (Legal Business Name): SHANA SUSANNE MEVISSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 AMHURST AVE # 3
WILTON NY
12831-1834
US

IV. Provider business mailing address

713 TROY SCHENECTADY RD STE 224
LATHAM NY
12110-2490
US

V. Phone/Fax

Practice location:
  • Phone: 517-778-5881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: