=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417261306
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SVETLANA SEROVA PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2010
-----------------------------------------------------
Last Update Date | 12/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1651 3RD AVE RM 205
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10128-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-231-1742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 BEVERLEY RD APT 1V
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11218-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-824-7630
-----------------------------------------------------
Fax | 212-426-4973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 68018554
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------