Healthcare Provider Details

I. General information

NPI: 1992390611
Provider Name (Legal Business Name): NICOLE TORI FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CHERRY AVE
BETHPAGE NY
11714-1531
US

IV. Provider business mailing address

55 CHERRY AVE
BETHPAGE NY
11714-1531
US

V. Phone/Fax

Practice location:
  • Phone: 516-361-9671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: