Provider Demographics
NPI:1831414283
Name:KOUMOS, NICHOLAS S
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:S
Last Name:KOUMOS
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 1:69 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1916
Mailing Address - Country:US
Mailing Address - Phone:516-596-0452
Mailing Address - Fax:
Practice Address - Street 1:8808 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1608
Practice Address - Country:US
Practice Address - Phone:718-634-8922
Practice Address - Fax:718-634-5740
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health