Provider Demographics
NPI:1720739329
Name:SHKLOVSKY, MARK (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHKLOVSKY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7116 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1823
Mailing Address - Country:US
Mailing Address - Phone:718-307-1577
Mailing Address - Fax:
Practice Address - Street 1:425 E 25TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2547
Practice Address - Country:US
Practice Address - Phone:212-772-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404829363LP0808X
NY746484163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse