Provider Demographics
NPI:1912667692
Name:MARK, KELISHA
Entity Type:Individual
Prefix:
First Name:KELISHA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELISHA
Other - Middle Name:
Other - Last Name:MELBOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:77 WATER ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-4401
Mailing Address - Country:US
Mailing Address - Phone:347-440-5869
Mailing Address - Fax:
Practice Address - Street 1:77 WATER ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-4401
Practice Address - Country:US
Practice Address - Phone:347-440-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100364104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker