Healthcare Provider Details

I. General information

NPI: 1003732066
Provider Name (Legal Business Name): TETYANA KOCHETKOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

1228 MULBERRY DR
MAHWAH NJ
07430-2343
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-1000
  • Fax:
Mailing address:
  • Phone: 718-724-9820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86032274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: