MEDICARE: SHANTEL CAMILE GAYNOR MSED MHC-LP

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1568151207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTEL CAMILE GAYNOR MSED MHC-LP

Provider Business Mailing Address
First Line	:	2860 BAILEY AVENUE SUITE 1A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1049
Country	:	US
Telephone Number	:	718-701-5833
Fax Number	:

Provider Business Practice Location Address
First Line	:	2860 BAILEY AVENUE SUITE 1A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-7227
Country	:	US
Telephone Number	:	718-701-5833
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/08/2023

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