Provider Demographics
NPI:1053686261
Name:SMITH-PEREZ, NICOLE KENDALL (CASAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KENDALL
Last Name:SMITH-PEREZ
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:KENDALL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 W 26TH ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1006
Mailing Address - Country:US
Mailing Address - Phone:212-696-1550
Mailing Address - Fax:212-696-1602
Practice Address - Street 1:37 W 26TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1006
Practice Address - Country:US
Practice Address - Phone:212-696-1550
Practice Address - Fax:212-696-1602
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27086101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850677Medicaid