Healthcare Provider Details

I. General information

NPI: 1205730579
Provider Name (Legal Business Name): SHAKORA JENNAY WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 BROADHOLLOW RD
MELVILLE NY
11747-3669
US

IV. Provider business mailing address

938 ISLIP AVE
BRENTWOOD NY
11717-8120
US

V. Phone/Fax

Practice location:
  • Phone: 516-280-1327
  • Fax: 516-453-1339
Mailing address:
  • Phone: 929-944-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1492394
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: