Provider Demographics
NPI:1033448535
Name:SCANTLEBURY, MICHELLE (LCSWR, CASAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SCANTLEBURY
Suffix:
Gender:F
Credentials:LCSWR, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2224
Mailing Address - Country:US
Mailing Address - Phone:718-415-2678
Mailing Address - Fax:
Practice Address - Street 1:21 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2224
Practice Address - Country:US
Practice Address - Phone:718-415-2678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0809141041C0700X, 1041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01013818Medicaid
NYA400092309Medicare PIN