Provider Demographics
NPI:1053670208
Name:KUTNER, SHANNON WALSH (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:WALSH
Last Name:KUTNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2650
Mailing Address - Country:US
Mailing Address - Phone:631-921-6611
Mailing Address - Fax:
Practice Address - Street 1:147 NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2650
Practice Address - Country:US
Practice Address - Phone:631-921-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0771601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical