Provider Demographics
NPI:1154883726
Name:NIXON, SHANEKA LAKEISHA
Entity type:Individual
Prefix:
First Name:SHANEKA
Middle Name:LAKEISHA
Last Name:NIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OLD COUNTRY RD STE 316
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1944
Mailing Address - Country:US
Mailing Address - Phone:516-279-5335
Mailing Address - Fax:
Practice Address - Street 1:500 OLD COUNTRY RD STE 316
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1944
Practice Address - Country:US
Practice Address - Phone:516-279-5335
Practice Address - Fax:718-520-6460
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP116539101YM0800X, 101YM0800X
NY35921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid