Provider Demographics
NPI:1366532335
Name:SHANNON, THERESA SARLUCA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:SARLUCA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 REDLEF ST
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4596
Mailing Address - Country:US
Mailing Address - Phone:631-758-6353
Mailing Address - Fax:
Practice Address - Street 1:445 OAK ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3111
Practice Address - Country:US
Practice Address - Phone:631-691-3347
Practice Address - Fax:631-691-3728
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058454-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNC1641Medicare ID - Type Unspecified