=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275282980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELENA SHADE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2022
-----------------------------------------------------
Last Update Date | 03/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 SHORE FRONT PKWY APT 10U
-----------------------------------------------------
City | ARVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11692-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-851-0566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7600 SHORE FRONT PKWY APT 10U
-----------------------------------------------------
City | ARVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11692-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-851-0566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 3055508
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------