Provider Demographics
NPI:1699341602
Name:FREDERICK, SHAUNA LOUISE CYNTHIA (LMSW)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:LOUISE CYNTHIA
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL # 1252
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6504
Mailing Address - Country:US
Mailing Address - Phone:347-216-0790
Mailing Address - Fax:212-410-5918
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:347-216-0790
Practice Address - Fax:212-410-5918
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108922104100000X
NY0992821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY25227128OtherUNITED HEALTHCARE