Healthcare Provider Details

I. General information

NPI: 1003734948
Provider Name (Legal Business Name): BASS NURSE PRACTITIONERS IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 LEXINGTON AVE FL 14
NEW YORK NY
10022-4503
US

IV. Provider business mailing address

641 LEXINGTON AVE FL 14
NEW YORK NY
10022-4503
US

V. Phone/Fax

Practice location:
  • Phone: 917-923-0569
  • Fax: 469-414-5292
Mailing address:
  • Phone: 917-923-0569
  • Fax: 469-414-5292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN SHAW
Title or Position: MANAGING MEMBER
Credential: NP-P, PMHNP-BC
Phone: 917-575-5662