Provider Demographics
NPI:1689118952
Name:ETZION, SHIRA
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:ETZION
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 1:45 HANOVER CT
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3921
Mailing Address - Country:US
Mailing Address - Phone:516-445-5012
Mailing Address - Fax:
Practice Address - Street 1:41 UNION SQ W
Practice Address - Street 2:SUITE 1328
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3236
Practice Address - Country:US
Practice Address - Phone:516-445-5012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03411106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist