Provider Demographics
NPI:1336591312
Name:BELLIS, SHIMON R (LMSW)
Entity Type:Individual
Prefix:MR
First Name:SHIMON
Middle Name:R
Last Name:BELLIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17660 UNION TPKE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1526
Mailing Address - Country:US
Mailing Address - Phone:240-355-3015
Mailing Address - Fax:347-331-0304
Practice Address - Street 1:1133 BROADWAY
Practice Address - Street 2:SUITE 1028
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7903
Practice Address - Country:US
Practice Address - Phone:240-355-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09541-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical