Provider Demographics
NPI:1851740179
Name:CO, SHELLEY
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:CO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EAST 210TH STREET
Mailing Address - Street 2:KLAU 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-920-4295
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2990302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry