Healthcare Provider Details

I. General information

NPI: 1750049763
Provider Name (Legal Business Name): SHEMICA AMANDA OUTLAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RADISSON PLZ FL 9
NEW ROCHELLE NY
10801-5768
US

IV. Provider business mailing address

667 STONELEIGH AVE STE 202
CARMEL NY
10512-2455
US

V. Phone/Fax

Practice location:
  • Phone: 914-369-1934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017764
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: