Healthcare Provider Details

I. General information

NPI: 1205773587
Provider Name (Legal Business Name): CHRISTINA ROSE PETKANAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 LEFFERTS BLVD STE 2F
KEW GARDENS NY
11415-1738
US

IV. Provider business mailing address

38 PRINCE LN
WESTBURY NY
11590-6244
US

V. Phone/Fax

Practice location:
  • Phone: 718-880-2468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number036359
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: