=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992680292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUSSE BEHAVIORAL WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2025
-----------------------------------------------------
Last Update Date | 08/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 PARK AVE S
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-515-1729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3963 MURDOCK AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10466-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-515-1729
-----------------------------------------------------
Fax | 347-682-4068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EREWARIFAGHA M HAIDOME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-281-0304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0106X
-----------------------------------------------------
Taxonomy Name | Occupational Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------