Provider Demographics
NPI:1750624789
Name:CARR, SHANNON JEAN (MS, CAS, NCSP, BCBA,)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JEAN
Last Name:CARR
Suffix:
Gender:F
Credentials:MS, CAS, NCSP, BCBA,
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 PENNICOTT CIR
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-9541
Mailing Address - Country:US
Mailing Address - Phone:585-303-7329
Mailing Address - Fax:
Practice Address - Street 1:6 N MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1581
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103TS0200X
NY1-15-18884103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool