Provider Demographics
NPI:1780291823
Name:NISHITA-HAWKINSON, AVA TAMIKO (LMSW)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:TAMIKO
Last Name:NISHITA-HAWKINSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 FALLSWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4800
Mailing Address - Country:US
Mailing Address - Phone:443-703-1420
Mailing Address - Fax:410-837-8802
Practice Address - Street 1:225 BROADWAY STE 1570
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3088
Practice Address - Country:US
Practice Address - Phone:650-281-5436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25920104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD383841200Medicaid