Provider Demographics
NPI:1073974143
Name:MCLEOD, TAKIYSHA
Entity Type:Individual
Prefix:
First Name:TAKIYSHA
Middle Name:
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 W DEAN ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2106
Mailing Address - Country:US
Mailing Address - Phone:917-757-2596
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE STE 704-2112
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4509
Practice Address - Country:US
Practice Address - Phone:855-249-3663
Practice Address - Fax:855-249-6362
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401983363LP0808X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health