Provider Demographics
NPI:1053932129
Name:SEALY, SHANTANAI LARESA
Entity type:Individual
Prefix:
First Name:SHANTANAI
Middle Name:LARESA
Last Name:SEALY
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 1:67 HALSTEAD ST APT 1104
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1419
Mailing Address - Country:US
Mailing Address - Phone:732-372-5804
Mailing Address - Fax:
Practice Address - Street 1:370 MEMORIAL PKWY STE 3
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1580
Practice Address - Country:US
Practice Address - Phone:908-689-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06331900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker