Provider Demographics
NPI:1215108014
Name:SHAH, KHATIMA (LCSW)
Entity type:Individual
Prefix:MS
First Name:KHATIMA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13359 116TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3112
Mailing Address - Country:US
Mailing Address - Phone:917-714-7248
Mailing Address - Fax:718-848-5952
Practice Address - Street 1:13359 116TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3112
Practice Address - Country:US
Practice Address - Phone:917-714-7248
Practice Address - Fax:718-848-5952
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074145-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical