Basic Information
| Provider Information | |||||||||
| NPI: | 1831525260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLERISME | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLERISME | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MHC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 SALEM RD | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169975547 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17810 WEXFORD TER | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114323050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186581123 | ||||||||
| FaxNumber: | 7186584641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P90679 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.