Provider Demographics
NPI:1598259269
Name:MINA, NICHOLE E
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:E
Last Name:MINA
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 1:50 W HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6220
Mailing Address - Country:US
Mailing Address - Phone:516-569-6600
Mailing Address - Fax:
Practice Address - Street 1:375 E BAY DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2350
Practice Address - Country:US
Practice Address - Phone:516-897-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty