MEDICARE: YELENA KONSTANTINOVICH

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	222Q00000X	Developmental Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19166834	OTHER	NY	EMBLEMHEALTH

General Provider Information

NPI Number	:	1518479096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YELENA KONSTANTINOVICH

Provider Business Mailing Address
First Line	:	2015 SHORE PKWY APT 10J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6857
Country	:	US
Telephone Number	:	646-229-8794
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 SHORE PKWY APT 10J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6857
Country	:	US
Telephone Number	:	646-229-8794
Fax Number	:

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

Provider Enumeration Date	:	10/24/2017
Last Update Date	:	10/24/2017

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