Provider Demographics
NPI:1467604918
Name:SHOUP, RICHARD WERTH (MFT)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WERTH
Last Name:SHOUP
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E END AVE
Mailing Address - Street 2:16A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1106
Mailing Address - Country:US
Mailing Address - Phone:212-628-1812
Mailing Address - Fax:
Practice Address - Street 1:10 E END AVE
Practice Address - Street 2:16A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1106
Practice Address - Country:US
Practice Address - Phone:212-628-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMFT000188106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMFT000188OtherMFT