Provider Demographics
NPI:1487199550
Name:NITZ, SHANNON (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NITZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:NITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3990 46TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11104-1408
Mailing Address - Country:US
Mailing Address - Phone:718-679-8786
Mailing Address - Fax:
Practice Address - Street 1:3990 46TH ST # 1
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11104-1408
Practice Address - Country:US
Practice Address - Phone:718-679-8786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC605662861041C0700X
NY0886651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical