=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205000833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELINA POLYAKOV LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2008
-----------------------------------------------------
Last Update Date | 04/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 AIRPORT EXECUTIVE PARK SUITE 152
-----------------------------------------------------
City | NANUET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10954-5261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-312-9473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40-09 MONROE ST
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-4950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-312-9473
-----------------------------------------------------
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 | 44SL05435900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 070111-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------