Provider Demographics
NPI:1750603627
Name:SHAH, MAMTA
Entity type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 13TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:348 13TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-5004
Practice Address - Country:US
Practice Address - Phone:718-788-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist