Provider Demographics
NPI:1124443775
Name:NIEVES, ANGEL O (PSYD)
Entity type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:O
Last Name:NIEVES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 W GRAY ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2027
Mailing Address - Country:US
Mailing Address - Phone:813-452-1555
Mailing Address - Fax:
Practice Address - Street 1:4411 W GRAY ST UNIT 1
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2027
Practice Address - Country:US
Practice Address - Phone:813-452-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4150103TC1900X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling