Provider Demographics
NPI:1295270791
Name:PAMPHILE, SHANTA KERINA (MA)
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:KERINA
Last Name:PAMPHILE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 TAYLOR AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-3774
Mailing Address - Country:US
Mailing Address - Phone:347-208-3313
Mailing Address - Fax:
Practice Address - Street 1:5676 RIVERDALE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-2138
Practice Address - Country:US
Practice Address - Phone:718-796-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18P01042101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18P01042Medicaid