Healthcare Provider Details

I. General information

NPI: 1033352802
Provider Name (Legal Business Name): TATYANA PUKHOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8002 KEW GARDENS RD
KEW GARDENS NY
11415-3600
US

IV. Provider business mailing address

2 MANOR CT
NEW HYDE PARK NY
11040-2110
US

V. Phone/Fax

Practice location:
  • Phone: 718-793-2182
  • Fax: 718-575-0839
Mailing address:
  • Phone: 718-793-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number070452-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: