MEDICARE: MR. PAUL JEFFREY SHAKER LCSW, MSW, M.DIV.

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	5251	CT

General Provider Information

NPI Number	:	1982797353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL JEFFREY SHAKER LCSW, MSW, M.DIV.

Provider Business Mailing Address
First Line	:	69 MAPLE AVE
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2337
Country	:	US
Telephone Number	:	203-525-8358
Fax Number	:	860-656-6743

Provider Business Practice Location Address
First Line	:	69 MAPLE AVE
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2337
Country	:	US
Telephone Number	:	203-525-8358
Fax Number	:	860-656-6743

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

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	03/16/2024

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