Provider Demographics
NPI:1538646567
Name:INNISS, NICOLE JUANITA (LCAT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JUANITA
Last Name:INNISS
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 W 1ST ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1726
Mailing Address - Country:US
Mailing Address - Phone:347-274-5361
Mailing Address - Fax:
Practice Address - Street 1:483 CLERMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2253
Practice Address - Country:US
Practice Address - Phone:718-643-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002237221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist