Basic Information
Provider Information | |||||||||
NPI: | 1457663866 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | A QUIET PLACE PSYCHOLOGICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1013 E 13TH ST APT A10 | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112304220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6466629647 | ||||||||
FaxNumber: | 7183602279 | ||||||||
Practice Location | |||||||||
Address1: | 1013 E 13TH ST APT A10 | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112304220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6466629647 | ||||||||
FaxNumber: | 7183602279 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2010 | ||||||||
LastUpdateDate: | 07/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VAKHNYANSKAYA | ||||||||
AuthorizedOfficialFirstName: | IRINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6466629647 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 016487 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
ID | Type | State | Issuer | Description | 02704676 | 05 | NY |   | MEDICAID |