Healthcare Provider Details

I. General information

NPI: 1811850910
Provider Name (Legal Business Name): MAURICE KENYATA HARDISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 WEIRFIELD ST
RIDGEWOOD NY
11385-5350
US

IV. Provider business mailing address

343 NEW YORK AVE APT 1R
JERSEY CITY NJ
07307-1103
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7820
  • Fax:
Mailing address:
  • Phone: 646-753-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37174
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: