Provider Demographics
NPI:1306857230
Name:TULL, SHANE MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MARK
Last Name:TULL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:549 THROOP AVE
Mailing Address - Street 2:3F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2434
Mailing Address - Country:US
Mailing Address - Phone:947-884-4135
Mailing Address - Fax:718-576-9424
Practice Address - Street 1:549 THROOP AVE
Practice Address - Street 2:3F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2434
Practice Address - Country:US
Practice Address - Phone:947-884-4135
Practice Address - Fax:718-576-9424
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0745571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical