Provider Demographics
NPI:1225524549
Name:LITVACK, SHIRA
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:LITVACK
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 1:77 CARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1904
Mailing Address - Country:US
Mailing Address - Phone:516-732-0111
Mailing Address - Fax:
Practice Address - Street 1:77 CARMAN AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1904
Practice Address - Country:US
Practice Address - Phone:516-732-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1206739171M00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty