1407103252 NPI number — DR. ADENA E SHOSHAN PSYD

Table of content: DR. ADENA E SHOSHAN PSYD (NPI 1407103252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407103252 NPI number — DR. ADENA E SHOSHAN PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOSHAN
Provider First Name:
ADENA
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407103252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 ALLENS CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-3309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-454-9904
Provider Business Mailing Address Fax Number:
585-286-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 ALLENS CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-454-9904
Provider Business Practice Location Address Fax Number:
585-286-4487
Provider Enumeration Date:
08/11/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  019295 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12423485 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".