Healthcare Provider Details

I. General information

NPI: 1730002643
Provider Name (Legal Business Name): SHANTAL BISHOP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 WHITEHOUSE AVE
ROOSEVELT NY
11575-1324
US

IV. Provider business mailing address

1019 VAN SICLEN AVE APT 4F
BROOKLYN NY
11207-9034
US

V. Phone/Fax

Practice location:
  • Phone: 516-309-1675
  • Fax: 516-223-3840
Mailing address:
  • Phone: 917-579-1627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP144802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: