Provider Demographics
NPI:1386994960
Name:RATLIFF, SHANELL MARCIA (MS ED)
Entity type:Individual
Prefix:MRS
First Name:SHANELL
Middle Name:MARCIA
Last Name:RATLIFF
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:MS
Other - First Name:SHANELL
Other - Middle Name:MARCIA
Other - Last Name:PUNTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7000 AUSTIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1022
Mailing Address - Country:US
Mailing Address - Phone:718-762-7633
Mailing Address - Fax:718-886-8694
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:718-886-8694
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1254429252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1254429Medicare Oscar/Certification