Provider Demographics
NPI:1831115948
Name:SHAGAM, ROBERTA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:
Last Name:SHAGAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 RARITAN AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2446
Mailing Address - Country:US
Mailing Address - Phone:848-391-8382
Mailing Address - Fax:
Practice Address - Street 1:202 RARITAN AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904
Practice Address - Country:US
Practice Address - Phone:848-391-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SCO51721001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ064957BFKMedicare ID - Type Unspecified