Healthcare Provider Details

I. General information

NPI: 1124443775
Provider Name (Legal Business Name): ANGEL O NIEVES PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 W GRAY ST UNIT 1
TAMPA FL
33609-2027
US

IV. Provider business mailing address

4411 W GRAY ST UNIT 1
TAMPA FL
33609-2027
US

V. Phone/Fax

Practice location:
  • Phone: 813-452-1555
  • Fax:
Mailing address:
  • Phone: 813-452-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4150
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: