Provider Demographics
NPI:1013065440
Name:SHELKOWITZ, RUSSELL BRIAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:BRIAN
Last Name:SHELKOWITZ
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 1:1346 CENTRE RD
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-3268
Mailing Address - Country:US
Mailing Address - Phone:917-838-3607
Mailing Address - Fax:
Practice Address - Street 1:251 RICHMOND HILL ROAD
Practice Address - Street 2:HEARTLAND PSYCHOLOGICAL SVCES PC
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-494-9397
Practice Address - Fax:718-761-1000
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR048935 1104100000X
NY0489351041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
N2R382Medicare UPIN