Healthcare Provider Details

I. General information

NPI: 1922352590
Provider Name (Legal Business Name): VLADA TARTSAKOV MSWB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7813 153RD AVE STE 1
HOWARD BEACH NY
11414-1771
US

IV. Provider business mailing address

236 NEPTUNE AVE
BROOKLYN NY
11235-6302
US

V. Phone/Fax

Practice location:
  • Phone: 718-374-3917
  • Fax:
Mailing address:
  • Phone: 212-219-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number682891121
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier08EI124711R1X00
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerCITY PRO GROUP INC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: