Healthcare Provider Details

I. General information

NPI: 1104319276
Provider Name (Legal Business Name): AYANNA OBANDO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 12TH ST FL 7
BROOKLYN NY
11249-1008
US

IV. Provider business mailing address

109 N 12TH ST FL 7
BROOKLYN NY
11249-1008
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number011973
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: