Provider Demographics
NPI:1366794323
Name:JOHN, SHANICE (LMSW)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARCIA LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2635
Mailing Address - Country:US
Mailing Address - Phone:845-641-0722
Mailing Address - Fax:
Practice Address - Street 1:1 MARCIA LN
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970
Practice Address - Country:US
Practice Address - Phone:845-641-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27628101YA0400X
NY103352104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103352OtherUNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPT