Healthcare Provider Details

I. General information

NPI: 1831439389
Provider Name (Legal Business Name): ANNA IVANOVA-TATLICI LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

IV. Provider business mailing address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

V. Phone/Fax

Practice location:
  • Phone: 718-375-1200
  • Fax:
Mailing address:
  • Phone: 718-375-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005246-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: