Healthcare Provider Details

I. General information

NPI: 1952912883
Provider Name (Legal Business Name): SHOKRI ENBAWE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 STATE ST
SCHENECTADY NY
12307-1511
US

IV. Provider business mailing address

24 MATILDA ST FL 2
ALBANY NY
12209-1508
US

V. Phone/Fax

Practice location:
  • Phone: 518-243-3300
  • Fax:
Mailing address:
  • Phone: 518-478-5968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number094293-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: