Healthcare Provider Details

I. General information

NPI: 1124835475
Provider Name (Legal Business Name): MARIA KHODAKOVSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HIGH ST
MONTICELLO NY
12701-1343
US

IV. Provider business mailing address

7292 STATE ROUTE 42
GRAHAMSVILLE NY
12740-7004
US

V. Phone/Fax

Practice location:
  • Phone: 845-791-8800
  • Fax: 845-791-7051
Mailing address:
  • Phone: 845-707-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number554618-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF407294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: