Provider Demographics
NPI:1659330314
Name:SHAH, PUNITA A (LCSW)
Entity Type:Individual
Prefix:
First Name:PUNITA
Middle Name:A
Last Name:SHAH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PANI
Other - Middle Name:A
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13851-0947
Mailing Address - Country:US
Mailing Address - Phone:607-786-0435
Mailing Address - Fax:607-786-0435
Practice Address - Street 1:1500 VESTAL PKWY E
Practice Address - Street 2:STE 102
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1830
Practice Address - Country:US
Practice Address - Phone:607-786-0435
Practice Address - Fax:607-786-0435
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0573201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01884115Medicaid
NY01884115Medicaid