Provider Demographics
NPI:1538794698
Name:HALEY, SHANNON (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 N BEECH ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2604
Mailing Address - Country:US
Mailing Address - Phone:516-672-5441
Mailing Address - Fax:
Practice Address - Street 1:1 CRAIG B GARIEPY AVE
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-2820
Practice Address - Country:US
Practice Address - Phone:631-650-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024590225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist