Provider Demographics
NPI:1255534368
Name:DASTUR, SHANA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:
Last Name:DASTUR
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 1:139 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7962
Mailing Address - Country:US
Mailing Address - Phone:718-208-3603
Mailing Address - Fax:
Practice Address - Street 1:406 10TH AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:718-488-0100
Practice Address - Fax:212-273-6507
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076100104100000X
NY0785401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker