Provider Demographics
NPI:1891360962
Name:JOHNSON, SHANELLE
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:JOHNSON
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 1:2079 SCHENECTADY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3130
Mailing Address - Country:US
Mailing Address - Phone:347-385-3848
Mailing Address - Fax:
Practice Address - Street 1:2381 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3122
Practice Address - Country:US
Practice Address - Phone:800-277-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-06-30
Deactivation Date:2021-05-21
Deactivation Code:
Reactivation Date:2021-06-30
Provider Licenses
StateLicense IDTaxonomies
NY103096104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker