=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588476584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANISHA MCCLENDON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2025
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16318 JAMAICA AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-4919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-358-8288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 332 RICHARD AVE APT D3
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-543-9281
-----------------------------------------------------
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 | 125497-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------