Healthcare Provider Details

I. General information

NPI: 1760209530
Provider Name (Legal Business Name): SHERIDAN BASCOMBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E MERRICK RD STE 304
VALLEY STREAM NY
11580-5800
US

IV. Provider business mailing address

10 E MERRICK RD STE 304
VALLEY STREAM NY
11580-5800
US

V. Phone/Fax

Practice location:
  • Phone: 516-875-2075
  • Fax: 516-386-9974
Mailing address:
  • Phone: 516-875-2075
  • Fax: 516-386-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP131283
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: