Basic Information
| Provider Information | |||||||||
| NPI: | 1720631963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELIZAIRE | ||||||||
| FirstName: | MOISE | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 PARK ST | ||||||||
| Address2: | |||||||||
| City: | SPRING VALLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109773933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458264272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 140 OLD ORANGEBURG RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109621157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453591000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F402640-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | F402640-1 | 01 | NY | NEW YORK EDUCATION DEPARTMENT | OTHER |