Healthcare Provider Details

I. General information

NPI: 1144151366
Provider Name (Legal Business Name): JASPER VICTOR OTVERTCHENKO LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 PINE WOODS ROAD SUITE 7
HYDE PARK NY
12538
US

IV. Provider business mailing address

7 PINE WOODS ROAD SUITE 7
HYDE PARK NY
12538
US

V. Phone/Fax

Practice location:
  • Phone: 845-233-5935
  • Fax: 845-233-4726
Mailing address:
  • Phone: 845-233-5935
  • Fax: 845-233-4726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number130929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: