Healthcare Provider Details

I. General information

NPI: 1942136825
Provider Name (Legal Business Name): TISHALEE MOESHA HUMBER I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19512 119TH AVE
SAINT ALBANS NY
11412-3436
US

IV. Provider business mailing address

19512 119TH AVE
SAINT ALBANS NY
11412-3436
US

V. Phone/Fax

Practice location:
  • Phone: 917-724-4865
  • Fax:
Mailing address:
  • Phone: 917-724-4865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131731
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: