=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114596129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KSENIA MAKAROVA LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2021
-----------------------------------------------------
Last Update Date | 06/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W 37TH ST APT 10F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-5630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-857-6826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 LEXINGTON DR
-----------------------------------------------------
City | NEWBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12550-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-857-6826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 104284-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------