Healthcare Provider Details

I. General information

NPI: 1225789092
Provider Name (Legal Business Name): SHAMARA NICHOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 41ST AVE
LONG ISLAND CITY NY
11101-2814
US

IV. Provider business mailing address

4348 ELY AVE
BRONX NY
10466-1816
US

V. Phone/Fax

Practice location:
  • Phone: 201-500-7693
  • Fax:
Mailing address:
  • Phone: 201-500-7693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number011313
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: