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General NPI Number Information
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NPI Number | 1154105609
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Entity Type | Organization
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Legal Business Name | PRACTICAL ONLINE THERAPY LCSW PLLC
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Dates
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Enumeration Date | 08/23/2023
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Last Update Date | 08/23/2023
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Provider Practice Location Address
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Address Line | 10417 35TH AVE
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City | CORONA
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State | NY
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Zip | 11368-1933
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Country | US
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Telephone | 347-848-2237
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Fax |
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Provider Business Mailing Address
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Address Line | 45 ECKERT ST
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City | HUNTINGTON STATION
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State | NY
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Zip | 11746-3842
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Country | US
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Telephone | 347-848-2237
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | MRS. NIXALY YAKUBOV
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Credential | LCSW
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Telephone | 347-848-2237
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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