Provider Demographics
NPI:1972570851
Name:SHAO, LIANG (PHD)
Entity type:Individual
Prefix:DR
First Name:LIANG
Middle Name:
Last Name:SHAO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 BROADWAY
Mailing Address - Street 2:17 FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4640
Mailing Address - Country:US
Mailing Address - Phone:212-851-8100
Mailing Address - Fax:212-537-0102
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-2272
Practice Address - Fax:718-771-1706
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015647103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02432162Medicaid
NYG300000304Medicare PIN
NYG400132617Medicare PIN
NYG400068397Medicare PIN
NY02432162Medicaid