1750458592 NPI number — MS. JODY ANN SHELBY LCSW

Table of content: MS. JODY ANN SHELBY LCSW (NPI 1750458592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750458592 NPI number — MS. JODY ANN SHELBY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELBY
Provider First Name:
JODY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1750458592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 MILBURN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE CENTRE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-678-0313
Provider Business Mailing Address Fax Number:
516-255-0036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 NORTH VILLAGE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 137
Provider Business Practice Location Address City Name:
ROCKVILLE CENTRE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-678-0313
Provider Business Practice Location Address Fax Number:
516-255-0036
Provider Enumeration Date:
11/29/2006

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: 104100000X , with the licence number:  R0323761 , 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: 11497548 . This is a "OXFORD HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7268737 . This is a "AETNA BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".




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