Healthcare Provider Details

I. General information

NPI: 1477072213
Provider Name (Legal Business Name): ILONA LEVINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CHICAGO AVE
STATEN ISLAND NY
10305-3757
US

IV. Provider business mailing address

75 W CASTOR PL
STATEN ISLAND NY
10312-1150
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-7828
  • Fax:
Mailing address:
  • Phone: 917-605-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096069-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: