MEDICARE: ELISSAVETA G IORDANOVA LCAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225600000X	Dance Therapist	002141-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9046310213	OTHER	NY	1199

General Provider Information

NPI Number	:	1265052807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISSAVETA G IORDANOVA LCAT

Provider Business Mailing Address
First Line	:	2588 AC POWELL BLVD APT 3M
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10039-2607
Country	:	US
Telephone Number	:	917-848-7199
Fax Number	:

Provider Business Practice Location Address
First Line	:	2588 AC POWELL BLVD APT 3M
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10039-2607
Country	:	US
Telephone Number	:	917-848-7199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	04/23/2020

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