=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750100111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAQUANNA D THOMAS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2024
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 AMSTERDAM AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-865-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1510 CASTLE HILL AVE # 1008
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-4399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-295-4849
-----------------------------------------------------
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 | 12143201
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------