Provider Demographics
NPI:1891422176
Name:ORTIZ-NIEVES, KYNAISHA (LAC)
Entity Type:Individual
Prefix:MS
First Name:KYNAISHA
Middle Name:
Last Name:ORTIZ-NIEVES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:KYNAISHA
Other - Middle Name:
Other - Last Name:ORTIZ-NIEVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:47 MILLER STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114
Mailing Address - Country:US
Mailing Address - Phone:973-596-4190
Mailing Address - Fax:
Practice Address - Street 1:47 MILLER STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114
Practice Address - Country:US
Practice Address - Phone:973-596-4190
Practice Address - Fax:973-639-6658
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00652200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health