=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043875552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. NATALYA V FRYAZIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2019
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 60TH ST. 2ND FLR
-----------------------------------------------------
City | WEST NEW YORK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-430-5233
-----------------------------------------------------
Fax | 201-210-4435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 PARK AVE APT 4D
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07087-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-404-3452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 37AC00469200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------