=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629597232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY BONIEL LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2925A KINGS HWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-382-0045
-----------------------------------------------------
Fax | 718-859-7157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2925A KINGS HWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-382-0045
-----------------------------------------------------
Fax | 718-859-7157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 101434
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------