Provider Demographics
NPI:1265946404
Name:AJENISHE, NICOLE DANIELLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:AJENISHE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1822
Mailing Address - Country:US
Mailing Address - Phone:516-263-3996
Mailing Address - Fax:
Practice Address - Street 1:6209 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-2702
Practice Address - Country:US
Practice Address - Phone:718-234-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY97629531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical