Healthcare Provider Details

I. General information

NPI: 1417866427
Provider Name (Legal Business Name): KIABETT SHANTALL PEGUERO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST FL 4
BRONX NY
10451-5589
US

IV. Provider business mailing address

590 E 166TH ST APT 5M
BRONX NY
10456-5682
US

V. Phone/Fax

Practice location:
  • Phone: 844-692-4692
  • Fax:
Mailing address:
  • Phone: 646-355-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131336
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: