Provider Demographics
NPI:1336676048
Name:SHADE, DOMINIQUE (LMSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SHADE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 VOYAGE DR
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-3514
Mailing Address - Country:US
Mailing Address - Phone:518-545-0195
Mailing Address - Fax:
Practice Address - Street 1:75 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3409
Practice Address - Country:US
Practice Address - Phone:518-549-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099317104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker