Healthcare Provider Details

I. General information

NPI: 1467087783
Provider Name (Legal Business Name): SHANKAR PANWAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/07/2020
Certification Date: 03/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

K 11, 1783 MERIDEN WATERBURY TPKE
SOUTHINGTON CT
06489
US

IV. Provider business mailing address

102 PEMBROKE RD
HAMDEN CT
06514-2626
US

V. Phone/Fax

Practice location:
  • Phone: 203-404-1010
  • Fax: 860-426-2898
Mailing address:
  • Phone: 203-668-3554
  • Fax: 860-426-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: