Provider Demographics
NPI:1366954083
Name:MCDOUGALD, SHANEA
Entity type:Individual
Prefix:
First Name:SHANEA
Middle Name:
Last Name:MCDOUGALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANEA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1050 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2007
Mailing Address - Country:US
Mailing Address - Phone:716-710-4393
Mailing Address - Fax:
Practice Address - Street 1:1050 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-2007
Practice Address - Country:US
Practice Address - Phone:716-710-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor