Provider Demographics
NPI:1275161978
Name:KNOWLES, NIAZA I
Entity Type:Individual
Prefix:
First Name:NIAZA
Middle Name:
Last Name:KNOWLES
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NYE
Other - Middle Name:
Other - Last Name:KNOWLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2062 POLO GARDENS DR APT 107
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2008
Mailing Address - Country:US
Mailing Address - Phone:561-660-0654
Mailing Address - Fax:
Practice Address - Street 1:2062 POLO GARDENS DR APT 107
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-2008
Practice Address - Country:US
Practice Address - Phone:561-660-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19289101YM0800X, 101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)