Provider Demographics
NPI:1982904066
Name:BURCH, SHANITA L
Entity Type:Individual
Prefix:
First Name:SHANITA
Middle Name:L
Last Name:BURCH
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 1:7 WILLOUGHBY ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4014
Mailing Address - Country:US
Mailing Address - Phone:631-704-4155
Mailing Address - Fax:
Practice Address - Street 1:151 BURRS LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6052
Practice Address - Country:US
Practice Address - Phone:631-643-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076436-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical