Healthcare Provider Details

I. General information

NPI: 1023426053
Provider Name (Legal Business Name): KEOVMORKODH KUCHARSKI M.S. CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEOVMORKODH CHHUON

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150-50 14TH ROAD
WHITESTONE NY
11357
US

IV. Provider business mailing address

244 5TH AVE STE J263
NEW YORK NY
10001-7604
US

V. Phone/Fax

Practice location:
  • Phone: 718-767-0091
  • Fax: 718-767-0086
Mailing address:
  • Phone: 310-661-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number23364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: