Provider Demographics
NPI:1447806195
Name:KOSTENBADER, SHAYNA (LCSW)
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:KOSTENBADER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHAYNA
Other - Middle Name:
Other - Last Name:FRENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:100 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1040
Mailing Address - Country:US
Mailing Address - Phone:845-394-1940
Mailing Address - Fax:
Practice Address - Street 1:146 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1808
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109841-01104100000X
390200000X
NY0968721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program