Provider Demographics
NPI:1528956885
Name:VICARI, SHANNON BLAIR
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:BLAIR
Last Name:VICARI
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 1:80 FERRY BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-6079
Mailing Address - Country:US
Mailing Address - Phone:203-772-9906
Mailing Address - Fax:
Practice Address - Street 1:80 FERRY BLVD STE 105
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-6079
Practice Address - Country:US
Practice Address - Phone:203-772-9906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2105103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst