Provider Demographics
NPI:1598017626
Name:ROSSCLARK, SHNIQUE
Entity Type:Individual
Prefix:MRS
First Name:SHNIQUE
Middle Name:
Last Name:ROSSCLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHNIQUE
Other - Middle Name:
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSED
Mailing Address - Street 1:2046 E 64TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5912
Mailing Address - Country:US
Mailing Address - Phone:917-312-5953
Mailing Address - Fax:
Practice Address - Street 1:60 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1600
Practice Address - Country:US
Practice Address - Phone:212-679-7867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-13
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst