Provider Demographics
NPI:1659093243
Name:OMIDI, MARYAM
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:OMIDI
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 1:158 WEST 124TH STREET
Mailing Address - Street 2:FLOOR 7, ROOM 721
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027
Mailing Address - Country:US
Mailing Address - Phone:332-243-0075
Mailing Address - Fax:
Practice Address - Street 1:411 W 114TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1710
Practice Address - Country:US
Practice Address - Phone:212-523-6489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical