Healthcare Provider Details

I. General information

NPI: 1750843959
Provider Name (Legal Business Name): TAMARA DEKHKANOVA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. TAMARA AVEZBAKIYEV

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7252 METROPOLITAN AVE STE 1
MIDDLE VILLAGE NY
11379-2103
US

IV. Provider business mailing address

11814 83RD AVE APT 4L
KEW GARDENS NY
11415-1365
US

V. Phone/Fax

Practice location:
  • Phone: 718-326-0055
  • Fax:
Mailing address:
  • Phone: 917-353-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number017290-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number017290-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number017290-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: