Provider Demographics
NPI:1063404143
Name:MUTHERSBAUGH, SHAWN HARRIS (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:HARRIS
Last Name:MUTHERSBAUGH
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 1:120 DEFREEST DR.,
Mailing Address - Street 2:175
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-390-6890
Mailing Address - Fax:518-374-6898
Practice Address - Street 1:120 DEFREEST DR.,
Practice Address - Street 2:175
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-390-6890
Practice Address - Fax:518-374-6898
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR032125104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01645743Medicaid
NY54915AMedicare PIN
NYR92027Medicare UPIN