Basic Information
| Provider Information | |||||||||
| NPI: | 1295270791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAMPHILE | ||||||||
| FirstName: | SHANTA | ||||||||
| MiddleName: | KERINA | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1438 TAYLOR AVE | ||||||||
| Address2: | APT 1 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104603774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472083313 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5676 RIVERDALE AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104712138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187965300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 18P01042 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 18P01042 | 05 | NY | MEDICAID |