Basic Information
| Provider Information | |||||||||
| NPI: | 1750624789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, CAS, NCSP, BCBA, | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRINCE | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23 PENNICOTT CIR | ||||||||
| Address2: | |||||||||
| City: | PENFIELD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145269541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853037329 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 N MAIN ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | FAIRPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144501581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 06/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103TS0200X | N | Behavioral Health & Social Service Providers | Psychologist | School | 103K00000X | 1-15-18884 | NY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.