Basic Information
| Provider Information | |||||||||
| NPI: | 1063096865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRUSHKA | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | MALKA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS, CGC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COHEN | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | MALKA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS, CGC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE STE 2850 | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322183 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE STE 2850 | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143045280 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2021 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | 17292 | NY | Y | Other Service Providers | Genetic Counselor, MS |
No ID Information.