MEDICARE: SHINY TRIANGLE LCSW PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103TB0200X	Cognitive & Behavioral Psychologist
2	103TC2200X	Clinical Child & Adolescent Psychologist
3	103TF0000X	Family Psychologist
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1164175105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINY TRIANGLE LCSW PC

Provider Business Mailing Address
First Line	:	254 OLD NYACK TPKE
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-5741
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1171 TOWNE ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45216-2227
Country	:	US
Telephone Number	:	212-734-6621
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAMUEL WEISER
Credential	:
Telephone Number	:	845-425-0982

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/10/2024

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