Provider Demographics
NPI:1497179709
Name:DOUGLAS, SHAUNTA
Entity Type:Individual
Prefix:
First Name:SHAUNTA
Middle Name:
Last Name:DOUGLAS
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 1:621 LEFFERTS AVE
Mailing Address - Street 2:APT. F1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1021
Mailing Address - Country:US
Mailing Address - Phone:347-526-0830
Mailing Address - Fax:
Practice Address - Street 1:271 NORTH AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-5104
Practice Address - Country:US
Practice Address - Phone:914-235-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker