Provider Demographics
NPI:1518640762
Name:SHANE, CARLA M
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:M
Last Name:SHANE
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 1:21 FAIRVIEW AVE APT L2
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-4122
Mailing Address - Country:US
Mailing Address - Phone:646-977-2245
Mailing Address - Fax:
Practice Address - Street 1:21 FAIRVIEW AVE APT L2
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-4122
Practice Address - Country:US
Practice Address - Phone:646-977-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency