Provider Demographics
NPI:1033412523
Name:TEVDORASHVILI, NINO (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:NINO
Middle Name:
Last Name:TEVDORASHVILI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21-05 LINDEN ST. SUITE-2D
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2405
Mailing Address - Country:US
Mailing Address - Phone:917-251-7437
Mailing Address - Fax:
Practice Address - Street 1:21-05 LINDEN ST. SUITE-2D
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2405
Practice Address - Country:US
Practice Address - Phone:917-251-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0045701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health