Provider Demographics
NPI:1780199075
Name:SIMPLICIO LEMOS, THAISA MARIA (CLC)
Entity Type:Individual
Prefix:
First Name:THAISA MARIA
Middle Name:
Last Name:SIMPLICIO LEMOS
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 IRVING PL APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2508
Mailing Address - Country:US
Mailing Address - Phone:347-766-4636
Mailing Address - Fax:
Practice Address - Street 1:49 IRVING PL APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2508
Practice Address - Country:US
Practice Address - Phone:347-766-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPP-252818174N00000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133N00000XDietary & Nutritional Service ProvidersNutritionist