Provider Demographics
NPI:1861930414
Name:BLACK, SHANTE
Entity type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 BROADWAY FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5666
Mailing Address - Country:US
Mailing Address - Phone:917-284-9393
Mailing Address - Fax:917-284-9393
Practice Address - Street 1:1178 BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5666
Practice Address - Country:US
Practice Address - Phone:917-284-9393
Practice Address - Fax:917-284-9393
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT999103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid