Provider Demographics
NPI:1376141663
Name:HYDE, SHENISSA M
Entity Type:Individual
Prefix:
First Name:SHENISSA
Middle Name:M
Last Name:HYDE
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 1:2765 MATTHEWS AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8620
Mailing Address - Country:US
Mailing Address - Phone:121-236-5847
Mailing Address - Fax:
Practice Address - Street 1:2765 MATTHEWS AVE APT 5A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-8620
Practice Address - Country:US
Practice Address - Phone:121-236-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty