Provider Demographics
NPI:1356871586
Name:SZOBESKY, SHANNON TAYLOR
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:SZOBESKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SWAN DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2255 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3499
Practice Address - Country:US
Practice Address - Phone:516-643-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2023-04-21
Deactivation Date:2020-09-14
Deactivation Code:
Reactivation Date:2020-10-28
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY010472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician