Provider Demographics
NPI:1720139108
Name:SHAFFERY, JOSEPH PETER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:PETER
Last Name:SHAFFERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 KALMIA ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1213
Mailing Address - Country:US
Mailing Address - Phone:631-912-9133
Mailing Address - Fax:631-912-9133
Practice Address - Street 1:1441 OLD NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2146
Practice Address - Country:US
Practice Address - Phone:516-625-6846
Practice Address - Fax:516-625-6849
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV82261Medicare ID - Type UnspecifiedMEDICARE