Provider Demographics
NPI:1689316093
Name:GRAYSON, SHANEQUA
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:GRAYSON
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 1:41 12TH AVE
Mailing Address - Street 2:#4
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:249 CLASSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-1440
Practice Address - Country:US
Practice Address - Phone:718-399-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker