Provider Demographics
NPI:1154141687
Name:EDMA, NICOLAS
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:EDMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2142 UTOPIA PKWY
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-4142
Practice Address - Country:US
Practice Address - Phone:718-767-0610
Practice Address - Fax:718-767-0260
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029525225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist