Provider Demographics
NPI:1407253537
Name:DISU, SHIRLEY (PSYD, NC-PSYA)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:
Last Name:DISU
Suffix:
Gender:F
Credentials:PSYD, NC-PSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2823
Mailing Address - Country:US
Mailing Address - Phone:718-285-4006
Mailing Address - Fax:
Practice Address - Street 1:920 48TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2918
Practice Address - Country:US
Practice Address - Phone:718-283-8128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000927102L00000X
NY024355-01103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst