Healthcare Provider Details

I. General information

NPI: 1245953959
Provider Name (Legal Business Name): SHASTA DANIELLE TREADWAY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 ROUTE 44 STE F
SALT POINT NY
12578-8040
US

IV. Provider business mailing address

2510 ROUTE 44 STE F
SALT POINT NY
12578-8040
US

V. Phone/Fax

Practice location:
  • Phone: 844-205-0773
  • Fax: 845-622-3636
Mailing address:
  • Phone: 844-205-0773
  • Fax: 845-622-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404416
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: