Provider Demographics
NPI:1326649146
Name:COSMIC PSYCH-MEDX
Entity Type:Organization
Organization Name:COSMIC PSYCH-MEDX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:HATSHEPSUT
Authorized Official - Middle Name:NOLENE
Authorized Official - Last Name:KISA-DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSTOM
Authorized Official - Phone:347-465-0684
Mailing Address - Street 1:PO BOX 260031
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-0031
Mailing Address - Country:US
Mailing Address - Phone:347-465-0684
Mailing Address - Fax:347-465-0684
Practice Address - Street 1:2065 E 54TH ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4750
Practice Address - Country:US
Practice Address - Phone:347-465-0684
Practice Address - Fax:347-465-0684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty