MEDICARE: SHANNON NITZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SC60566286	WA
2	1041C0700X	Clinical Social Worker	088665	NY

General Provider Information

NPI Number	:	1487199550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON NITZ LCSW

Provider Business Mailing Address
First Line	:	3990 46TH ST # 1
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11104-1408
Country	:	US
Telephone Number	:	718-679-8786
Fax Number	:

Provider Business Practice Location Address
First Line	:	3990 46TH ST # 1
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11104-1408
Country	:	US
Telephone Number	:	718-679-8786
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	02/02/2021

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Directions to “ SHANNON NITZ LCSW” Practice Location

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