Provider Demographics
NPI:1790272706
Name:THELISMA, FREEDGY
Entity Type:Individual
Prefix:
First Name:FREEDGY
Middle Name:
Last Name:THELISMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 E 51ST ST APT 6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2339
Mailing Address - Country:US
Mailing Address - Phone:917-553-5481
Mailing Address - Fax:
Practice Address - Street 1:248 E 51ST ST APT 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2339
Practice Address - Country:US
Practice Address - Phone:917-553-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103214104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker