MEDICARE: NICKOSHA ALISA WAYNE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	103162	NY

General Provider Information

NPI Number	:	1093526345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKOSHA ALISA WAYNE LCSW

Provider Business Mailing Address
First Line	:	4223 SETON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2119
Country	:	US
Telephone Number	:	347-638-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	4223 SETON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-2119
Country	:	US
Telephone Number	:	347-638-1002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2025
Last Update Date	:	05/27/2026

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