=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134739311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANELL PEARL KITT LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2020
-----------------------------------------------------
Last Update Date | 08/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 329 E 149TH ST FL 4
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10451-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-982-7328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 871 E 220TH ST APT 9
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-982-7328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 103125
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------