=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356641526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON CATHERINE CULLEN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 W 9TH ST APT 3D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-8923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-659-9482
-----------------------------------------------------
Fax | 516-659-9482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4554 39TH PL APT 4A
-----------------------------------------------------
City | SUNNYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11104-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-659-9482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 72078091
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 081649
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------