Healthcare Provider Details

I. General information

NPI: 1629904792
Provider Name (Legal Business Name): PRINCESS LEAH IDOWU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 JAY ST STE 501
BROOKLYN NY
11201-4398
US

IV. Provider business mailing address

667 STONELEIGH AVE STE 202
CARMEL NY
10512-2455
US

V. Phone/Fax

Practice location:
  • Phone: 347-304-9465
  • Fax:
Mailing address:
  • Phone: 845-279-5908
  • Fax: 845-622-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18-P145487-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: