Provider Demographics
NPI:1093778144
Name:ZYSMAN, SHAFER H
Entity Type:Individual
Prefix:
First Name:SHAFER
Middle Name:H
Last Name:ZYSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STILLWATER RD
Mailing Address - Street 2:
Mailing Address - City:ST JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-3914
Mailing Address - Country:US
Mailing Address - Phone:631-686-6359
Mailing Address - Fax:631-647-7893
Practice Address - Street 1:160 HOWELLS RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5320
Practice Address - Country:US
Practice Address - Phone:631-647-7885
Practice Address - Fax:631-647-7893
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025669104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01428344Medicaid
NYN20072Medicare ID - Type Unspecified