Provider Demographics
NPI:1093870834
Name:PETNOV-SHERMAN, MICHELLE(SHELLY) (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE(SHELLY)
Middle Name:
Last Name:PETNOV-SHERMAN
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 1:2000 BROADWAY
Mailing Address - Street 2:SUITE 10G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5028
Mailing Address - Country:US
Mailing Address - Phone:212-595-5210
Mailing Address - Fax:212-595-5545
Practice Address - Street 1:2000 BROADWAY
Practice Address - Street 2:SUITE 10G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5028
Practice Address - Country:US
Practice Address - Phone:212-595-5210
Practice Address - Fax:212-595-5545
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR037234-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical