MEDICARE: STACEY SHANE-NUSBAUM 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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker	SW16157

General Provider Information

NPI Number	:	1740840040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY SHANE-NUSBAUM LCSW

Provider Business Mailing Address
First Line	:	6039 COLLINS AVE APT 1711
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-2256
Country	:	US
Telephone Number	:	305-989-5493
Fax Number	:	954-885-9444

Provider Business Practice Location Address
First Line	:	6039 COLLINS AVE APT 1711
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-2256
Country	:	US
Telephone Number	:	305-989-5493
Fax Number	:

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	03/08/2024

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