Healthcare Provider Details

I. General information

NPI: 1265188551
Provider Name (Legal Business Name): NISA GUZMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 646-750-0363
  • Fax:
Mailing address:
  • Phone: 646-750-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092870
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: