Provider Demographics
NPI:1972526820
Name:SHRADER, GARY (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SHRADER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E 10TH ST APT 2W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-5047
Mailing Address - Country:US
Mailing Address - Phone:646-265-4125
Mailing Address - Fax:
Practice Address - Street 1:321 E 10TH ST APT 2W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-5047
Practice Address - Country:US
Practice Address - Phone:646-265-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0731701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00073170Medicaid
NY00073170Medicaid