Healthcare Provider Details

I. General information

NPI: 1578088662
Provider Name (Legal Business Name): KELLY NICELEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 MARCUS GARVEY BLVD APT 4
BROOKLYN NY
11216-2448
US

IV. Provider business mailing address

410 MARCUS GARVEY BLVD APT 4
BROOKLYN NY
11216-2448
US

V. Phone/Fax

Practice location:
  • Phone: 917-513-3188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number0014493-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: