Basic Information
| Provider Information | |||||||||
| NPI: | 1467087783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANWAR | ||||||||
| FirstName: | SHANKAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 PEMBROKE RD | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065142626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036683554 | ||||||||
| FaxNumber: | 8604262898 | ||||||||
| Practice Location | |||||||||
| Address1: | K 11, 1783 MERIDEN WATERBURY TPKE | ||||||||
| Address2: | |||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034041010 | ||||||||
| FaxNumber: | 8604262898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2020 | ||||||||
| LastUpdateDate: | 03/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.