Provider Demographics
NPI:1467879197
Name:SMITH, SHAWN ANGELIQUE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:ANGELIQUE
Last Name:SMITH
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 1:1438 NOAH RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1345
Mailing Address - Country:US
Mailing Address - Phone:347-977-3269
Mailing Address - Fax:
Practice Address - Street 1:56 BEACH ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2702
Practice Address - Country:US
Practice Address - Phone:718-720-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080800-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker