Healthcare Provider Details

I. General information

NPI: 1548832314
Provider Name (Legal Business Name): KENDAHL SHORTWAY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MAIN ST
SPARTA NJ
07871-1937
US

IV. Provider business mailing address

136 GLEN RD EXT
HIGHLAND LAKES NJ
07422-1919
US

V. Phone/Fax

Practice location:
  • Phone: 908-246-0553
  • Fax:
Mailing address:
  • Phone: 201-463-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6459
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: