Provider Demographics
NPI:1548913486
Name:JOSEPH, SHAWN (NP)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1108
Mailing Address - Country:US
Mailing Address - Phone:917-530-2138
Mailing Address - Fax:
Practice Address - Street 1:28 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2709
Practice Address - Country:US
Practice Address - Phone:917-530-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01440100363LP0808X
NY404537363LP0808X, 363LP0808X
NY740997163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult