MEDICARE: MICHELLE ALEXANDRA NIZHNIKOV LMSW

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	103TC2200X	Clinical Child & Adolescent Psychologist	120101	NY

General Provider Information

NPI Number	:	1366129256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ALEXANDRA NIZHNIKOV LMSW

Provider Business Mailing Address
First Line	:	693 FLATBUSH AVE APT 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11225-6045
Country	:	US
Telephone Number	:	781-775-2634
Fax Number	:

Provider Business Practice Location Address
First Line	:	693 FLATBUSH AVE APT 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11225-6045
Country	:	US
Telephone Number	:	781-775-2634
Fax Number	:

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

Provider Enumeration Date	:	07/03/2023
Last Update Date	:	07/03/2023

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