Provider Demographics
NPI:1205418555
Name:NIMOH, MARIAN O
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:O
Last Name:NIMOH
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 1:19443 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2022
Mailing Address - Country:US
Mailing Address - Phone:347-858-4232
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA61483851103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst