=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972570851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIANG SHAO PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2006
-----------------------------------------------------
Last Update Date | 06/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 CLARKSON AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11203-2057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-245-2272
-----------------------------------------------------
Fax | 718-771-1706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1745 BROADWAY 17 FL
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-4640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-851-8100
-----------------------------------------------------
Fax | 212-537-0102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 015647
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 015647
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------