Provider Demographics
NPI:1932898350
Name:WRIGHT, SHANTAH NICHOLL (LSW)
Entity type:Individual
Prefix:MS
First Name:SHANTAH
Middle Name:NICHOLL
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2082
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07019-2082
Mailing Address - Country:US
Mailing Address - Phone:347-464-8775
Mailing Address - Fax:
Practice Address - Street 1:2041 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:VAUXHALL
Practice Address - State:NJ
Practice Address - Zip Code:07088-1220
Practice Address - Country:US
Practice Address - Phone:347-464-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05668300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health