Provider Demographics
NPI: | 1033448535 |
---|---|
Name: | SCANTLEBURY, MICHELLE (LCSWR, CASAC) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHELLE |
Middle Name: | |
Last Name: | SCANTLEBURY |
Suffix: | |
Gender: | F |
Credentials: | LCSWR, CASAC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 21 GEORGIA ST |
Mailing Address - Street 2: | |
Mailing Address - City: | VALLEY STREAM |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11580-2224 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-415-2678 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 21 GEORGIA ST |
Practice Address - Street 2: | |
Practice Address - City: | VALLEY STREAM |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11580-2224 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-415-2678 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-12-11 |
Last Update Date: | 2021-10-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 080914 | 1041C0700X, 1041C0700X |
101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 01013818 | Medicaid | |
NY | A400092309 | Medicare PIN |