Provider Demographics
NPI:1710778063
Name:SHANNON, MARIE LENA (LMHC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LENA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2907
Mailing Address - Country:US
Mailing Address - Phone:631-241-5525
Mailing Address - Fax:
Practice Address - Street 1:5000 EXPRESSWAY DR S
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1814
Practice Address - Country:US
Practice Address - Phone:631-241-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health