Provider Demographics
NPI:1912303876
Name:MOBLEY, SHANA
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:
Last Name:MOBLEY
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 1:2013 E 53RD ST
Mailing Address - Street 2:APT. # 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4732
Mailing Address - Country:US
Mailing Address - Phone:347-280-1635
Mailing Address - Fax:
Practice Address - Street 1:2013 E 53RD ST
Practice Address - Street 2:APT. # 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4732
Practice Address - Country:US
Practice Address - Phone:347-280-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1147064222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist