Healthcare Provider Details

I. General information

NPI: 1174453609
Provider Name (Legal Business Name): ANTONINA PAVLENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 UNION ST APT 2F
BROOKLYN NY
11215-1112
US

IV. Provider business mailing address

671 UNION ST APT 2F
BROOKLYN NY
11215-1112
US

V. Phone/Fax

Practice location:
  • Phone: 719-360-8836
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: