Provider Demographics
NPI:1629370069
Name:SHANLY, JOSEPH TIMOTHY (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:TIMOTHY
Last Name:SHANLY
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4601
Mailing Address - Country:US
Mailing Address - Phone:315-783-9114
Mailing Address - Fax:315-642-3249
Practice Address - Street 1:32735 COUNTY ROUTE 29 STE A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:NY
Practice Address - Zip Code:13673-4210
Practice Address - Country:US
Practice Address - Phone:315-642-3142
Practice Address - Fax:315-642-3249
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0644701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1730480179Medicaid