Healthcare Provider Details

I. General information

NPI: 1306471974
Provider Name (Legal Business Name): NIKADIA TASHANA LEWIS MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 E 138TH ST
BRONX NY
10454-1932
US

IV. Provider business mailing address

804 E 138TH ST
BRONX NY
10454-1932
US

V. Phone/Fax

Practice location:
  • Phone: 718-665-7500
  • Fax:
Mailing address:
  • Phone: 718-665-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP104441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: