Provider Demographics
NPI:1801220215
Name:ROEBACK, SHIRELL (LMSW)
Entity Type:Individual
Prefix:
First Name:SHIRELL
Middle Name:
Last Name:ROEBACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 VANDERBILT AVE
Mailing Address - Street 2:#132
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-3512
Mailing Address - Country:US
Mailing Address - Phone:347-693-1351
Mailing Address - Fax:347-365-4350
Practice Address - Street 1:593 VANDERBILT AVE
Practice Address - Street 2:#132
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-3512
Practice Address - Country:US
Practice Address - Phone:347-693-1351
Practice Address - Fax:347-365-4350
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072489-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY072489-1Medicaid