Healthcare Provider Details

I. General information

NPI: 1831635820
Provider Name (Legal Business Name): ELENA HATZAKOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

4404 QUEENS BLVD 2ND FLOOR
SUNNYSIDE NY
11104-2406
US

IV. Provider business mailing address

6120 WOODSIDE AVE LOWER LEVEL
WOODSIDE NY
11377-3577
US

V. Phone/Fax

Practice location:
  • Phone: 718-706-1663
  • Fax:
Mailing address:
  • Phone: 718-392-3516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number091800-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: