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General NPI Number Information
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NPI Number | 1326649146
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Entity Type | Organization
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Legal Business Name | COSMIC PSYCH-MEDX
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Dates
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Enumeration Date | 11/06/2020
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Last Update Date | 11/06/2020
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Provider Practice Location Address
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Address Line | 2065 E 54TH ST APT 2
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City | BROOKLYN
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State | NY
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Zip | 11234-4750
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Country | US
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Telephone | 347-465-0684
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Fax | 347-465-0684
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Provider Business Mailing Address
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Address Line | PO BOX 260031
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City | BROOKLYN
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State | NY
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Zip | 11226-0031
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Country | US
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Telephone | 347-465-0684
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Fax | 347-465-0684
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Authorized Official
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Title or Position | CHIEF CLINICIAN
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Name | MS. HATSHEPSUT NOLENE KISA-DAVIDSON
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Credential | MSTOM
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Telephone | 347-465-0684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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