Healthcare Provider Details

I. General information

NPI: 1467181214
Provider Name (Legal Business Name): MICAELLA IPSAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 KINGSBRIDGE AVE
BRONX NY
10463-5514
US

IV. Provider business mailing address

530 W 136TH ST APT 43
NEW YORK NY
10031-7962
US

V. Phone/Fax

Practice location:
  • Phone: 646-204-2295
  • 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: