Provider Demographics
NPI:1093302200
Name:SHIPMAN, TELEGRE M
Entity Type:Individual
Prefix:
First Name:TELEGRE
Middle Name:M
Last Name:SHIPMAN
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 1:2000 VALENTINE AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-3838
Mailing Address - Country:US
Mailing Address - Phone:191-740-5193
Mailing Address - Fax:
Practice Address - Street 1:2000 VALENTINE AVE APT 104
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-3838
Practice Address - Country:US
Practice Address - Phone:917-405-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31161228Medicaid