Provider Demographics
NPI:1629749742
Name:CORREA, NIVA LYSANDRA (LMHC)
Entity Type:Individual
Prefix:MS
First Name:NIVA
Middle Name:LYSANDRA
Last Name:CORREA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WALTER ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1136
Mailing Address - Country:US
Mailing Address - Phone:917-701-8525
Mailing Address - Fax:
Practice Address - Street 1:28 E OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4292
Practice Address - Country:US
Practice Address - Phone:917-701-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010919101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010919OtherLICENSED