Provider Demographics
NPI:1063678555
Name:OUTEDA, NICHOLAS ERNESTO (LMHC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ERNESTO
Last Name:OUTEDA
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 SEAGIRT BLVD
Mailing Address - Street 2:APT 5F
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-5950
Mailing Address - Country:US
Mailing Address - Phone:718-868-0515
Mailing Address - Fax:
Practice Address - Street 1:4130 75TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1852
Practice Address - Country:US
Practice Address - Phone:347-423-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000758-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health