Provider Demographics
NPI:1497264220
Name:SHAH, DHARA (LMHC, CASAC, NCC)
Entity Type:Individual
Prefix:
First Name:DHARA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:LMHC, CASAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BROWN PL
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5254
Mailing Address - Country:US
Mailing Address - Phone:973-870-1972
Mailing Address - Fax:
Practice Address - Street 1:110 N OCEAN AVE STE B
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2015
Practice Address - Country:US
Practice Address - Phone:973-870-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32618101YA0400X
NY008203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)