Healthcare Provider Details

I. General information

NPI: 1215750419
Provider Name (Legal Business Name): NIA KUTTAMPEROOR LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/07/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 BROADWAY
NEW YORK NY
10010-6008
US

IV. Provider business mailing address

928 BROADWAY
NEW YORK NY
10010-6008
US

V. Phone/Fax

Practice location:
  • Phone: 833-775-6252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07108200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: