Provider Demographics
NPI:1619156122
Name:MALTZMAN, SHANA (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:
Last Name:MALTZMAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:
Other - Last Name:DUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:27 BASCOM PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4203
Mailing Address - Country:US
Mailing Address - Phone:917-583-6537
Mailing Address - Fax:718-749-0110
Practice Address - Street 1:27 BASCOM PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4203
Practice Address - Country:US
Practice Address - Phone:917-583-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054208-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN4V091Medicare UPIN