MEDICARE: TEONA GOCHOLEISHVILI ABA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1407385982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEONA GOCHOLEISHVILI ABA

Provider Business Mailing Address
First Line	:	1545 DAHILL RD APT E1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-3545
Country	:	US
Telephone Number	:	216-396-5873
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 DAHILL RD
Second Line	:	APT E1
City	:	BROOKLYN
State	:	NY
Zip	:	11204
Country	:	US
Telephone Number	:	216-396-5873
Fax Number	:

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

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	07/21/2022

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