MEDICARE: NIZAMMAH WARD, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1235837592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIZAMMAH WARD, LLC

Provider Business Mailing Address
First Line	:	5500 DR MARTIN LUTHER KING JR ST S
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33705-5139
Country	:	US
Telephone Number	:	727-455-2511
Fax Number	:

Provider Business Practice Location Address
First Line	:	3530 1ST AVE N STE 205
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33713-8442
Country	:	US
Telephone Number	:	727-351-3251
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NIZAMMAH WARD
Credential	:
Telephone Number	:	727-351-3251

Provider Enumeration Date	:	02/16/2023
Last Update Date	:	02/16/2023

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