MEDICARE: MRS. YELENA COSSACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	1679037231	NY

General Provider Information

NPI Number	:	1093404881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. YELENA COSSACK

Provider Business Mailing Address
First Line	:	241 FAIRBANKS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4103
Country	:	US
Telephone Number	:	917-392-3352
Fax Number	:

Provider Business Practice Location Address
First Line	:	241 FAIRBANKS AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4103
Country	:	US
Telephone Number	:	917-392-3352
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	05/05/2023

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