Provider Demographics
NPI:1356600845
Name:CAMP SHANE
Entity type:Organization
Organization Name:CAMP SHANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-797-9977
Mailing Address - Street 1:134 TEATOWN RD
Mailing Address - Street 2:
Mailing Address - City:CROTON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10520-3524
Mailing Address - Country:US
Mailing Address - Phone:626-797-9977
Mailing Address - Fax:
Practice Address - Street 1:134 TEATOWN RD
Practice Address - Street 2:
Practice Address - City:CROTON ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10520-3524
Practice Address - Country:US
Practice Address - Phone:626-797-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANE FIT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR049213-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty