Healthcare Provider Details

I. General information

NPI: 1235448044
Provider Name (Legal Business Name): ANGELA SHISTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 NEPTUNE AVE RM 200
BROOKLYN NY
11224-4010
US

IV. Provider business mailing address

532 NEPTUNE AVE RM 200
BROOKLYN NY
11224-4010
US

V. Phone/Fax

Practice location:
  • Phone: 718-946-2600
  • Fax: 718-946-0226
Mailing address:
  • Phone: 718-946-2600
  • Fax: 718-946-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR043689-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: