Provider Demographics
NPI:1841432879
Name:SHAFFER, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:SHAFFER
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 1:12604 CRONSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1735
Mailing Address - Country:US
Mailing Address - Phone:917-692-4591
Mailing Address - Fax:
Practice Address - Street 1:202 AVENUE C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4514
Practice Address - Country:US
Practice Address - Phone:718-438-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY765212252Y00000X
NY026131-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency