Basic Information
| Provider Information | |||||||||
| NPI: | 1427478346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAIMONDO | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAW | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1055 E COLORADO BLVD STE 560 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911062380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552953276 | ||||||||
| FaxNumber: | 8008197806 | ||||||||
| Practice Location | |||||||||
| Address1: | 5266 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552953276 | ||||||||
| FaxNumber: | 8008197806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 001279 | NY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-13-14477 | NJ | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.