Provider Demographics
NPI:1902089238
Name:KELLEY, SHANNON KATHLEEN (PMHNP, LCSW, CASAC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PMHNP, LCSW, CASAC
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:CORCORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP, LCSW, CASAC
Mailing Address - Street 1:713 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2305
Mailing Address - Country:US
Mailing Address - Phone:315-464-7655
Mailing Address - Fax:
Practice Address - Street 1:713 HARRISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2305
Practice Address - Country:US
Practice Address - Phone:315-464-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082228-11041C0700X
NY740606163W00000X
NY403004363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse